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Run care gap analysis on a patient cohort

Run care gap analysis against a saved cohort, using the full record rather than structured fields alone, and open the Patient Timeline behind any flagged gap before anyone acts on it. If the measure comes from a published guideline rather than an established measure set, define the cohort first in Turn a clinical guideline into measurable cohort criteria, then start at Step 2 below.

Care Gap Analysis for Your Patient Cohort

Who this is for​

Anyone accountable for a measure a population is either meeting or missing: population health and quality improvement teams, care management nurses and outreach coordinators who work the resulting list, quality analysts and reporting teams at health systems, ACOs and payers, specialty program leads running disease-specific follow-up, and clinical informatics teams maintaining the measure definitions.

Why it matters​

A care management team works a diabetes population against a standard gap set: HbA1c not drawn in twelve months, retinal exam overdue, statin absent for patients over 40. The list comes from claims and structured EHR fields. A meaningful share of the flagged patients had the retinal exam, at an optometry practice that faxed the result, which arrived as a scanned PDF that no structured query reads.

The cost of that is not only wasted outreach. A nurse who calls three patients who already had the test stops trusting the fourth entry on the list, and the whole worklist loses credibility.

The gap set changes with the program: eGFR monitoring in chronic kidney disease, guideline-directed therapy in heart failure, surveillance imaging in cancer survivorship, preventive screening across primary care. The workflow does not change.

What you gain​

Gaps computed against the full record, including facts extracted from scanned and narrative documents, and a Patient Timeline the nurse opens before making the call. The reviewer confirms the gap against the supporting evidence, then works it. The exported CSV becomes an outreach worklist that survives scrutiny from the clinicians whose panels it names.

Patient Journey Intelligence identifies and evidences the gap. Clinical judgment about what to do for the patient stays with the care team.

Before you start​

  • Patient data ingested, including outside records and scanned documents. Skipping those reproduces the false-positive problem this workflow exists to fix
  • A saved cohort, built in Assistant or Cohort Builder, or translated from a guideline in Turn a clinical guideline into measurable cohort criteria
  • Access to the Care Gap Analyzer and to Patient Timeline for the reviewers who will validate results

Step 1: Select or build the cohort the measure applies to​

Skip this step if the cohort already exists.

  1. In the left navigation, go to Agents and Tools > Assistant or Cohort Builder.
  2. Select an existing saved cohort, or create one from a clinical question, for example: "Find patients with diabetes who had visits in the last year."
  3. Review the returned population and apply any further diagnosis, medication, measurement, visit, age, or date filters the measure requires.
  4. Exclude patients that should not be in the denominator, and confirm the cohort name and description.
  5. Save the cohort.

Step 2: Run Care Gap Analyzer against the cohort​

  1. In the left navigation, go to Agents and Tools > Care Gap Analyzer.
  2. Start a new care gap analysis.
  3. Select the saved cohort.
  4. Select the target condition, care topic, or measure to evaluate.
  5. Review the suggested criteria or care-gap definition.
  6. Adjust the criteria if review or configuration is available.
  7. Start the care gap analysis.
  8. Wait until the care gap job status is Completed.
  9. Open the completed care gap results.

Step 3: Triage the results by gap status​

  1. Review the patient-level care gap results.
  2. Identify patients marked as open, overdue, missing evidence, or requiring follow-up.
  3. Review the explanation for each gap status.
  4. Sort or filter the results by gap status, priority, due date, or available evidence where supported.
  5. Select a patient that requires clinical context or evidence review.
  6. Open the patient details or patient timeline from the care gap result.

Step 4: Confirm a gap against the Patient Timeline and its source documents​

  1. Review the patient timeline for diagnoses, visits, medications, measurements, procedures, and relevant clinical events.
  2. Check whether the timeline contains evidence that supports or resolves the care gap.
  3. Open supporting source documents when more detail is needed.
  4. Compare the care gap explanation with the patient timeline and source evidence.
  5. Confirm whether the gap appears valid, resolved, or uncertain.
  6. Add review notes or update the care gap decision where the workflow supports it.
  7. Return to the care gap results list and continue reviewing additional patients.

Step 5: Export the validated outreach worklist​

  1. Review the final care gap results before sharing or follow-up.
  2. Confirm that the selected patients and gap statuses match the intended outreach or quality-improvement workflow.
  3. Click Export CSV to export the care gap results.
  4. Include relevant patient identifiers, gap status, due date, explanation, and review notes in the exported file where available.
  5. Share the CSV with the care-management or quality team according to the approved team workflow.
  6. Use the patient timeline and supporting documents as context for follow-up decisions.

Recipe reference​

Each stage of this scenario is also a reusable building block.

These steps have their own pages:

Run care gap analysis from a saved cohort​

When to use on its own: For quality improvement, population health, or care-management workflows.
Features involved: Cohort Builder, Care Gap Analyzer, Patient Timeline, result export.
Edge cases / limitations: Care-gap analysis consumes an existing cohort; it does not create one. Missing source data can look like an open gap.
Value: Turns patient data into an actionable quality-improvement worklist.

Review a Patient Timeline before taking action​

When to use on its own: When you need patient context before accepting an extraction, confirming a gap, or reviewing a registry case.
Features involved: Patient Timeline, patient details, source document review, patient-level assistant where available.
Edge cases / limitations: Timeline completeness depends on ingested source data. Missing events may reflect missing source data rather than absence of care.
Value: Helps you trust and validate outputs before acting.