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Cohort to care gap to Patient Timeline

This scenario demonstrates how to select or create a patient cohort, run care gap analysis for a target condition or quality topic, review patients with open or overdue gaps, inspect the patient timeline for clinical context, and export the care gap results as a CSV file.

Best for: quality improvement and care-management demos.

Step 1: Create or select a chronic disease cohort​

  1. In the left navigation, go to Agents and Tools > Assistant or Cohort Builder.
  2. Create a new cohort using a clinical question, or select an existing saved cohort.
  3. For example, ask: "Find patients with diabetes who had visits in the last year."
  4. Review the cohort criteria and returned patient population.
  5. Apply additional filters if needed, such as diagnosis, medication, measurement, visit, age, or date criteria.
  6. Review the patient list and exclude any patients that should not be included.
  7. Enter or confirm the cohort name, description, category, and linked cohort information.
  8. Review the final cohort configuration.
  9. Click Create Cohort or save the updated cohort.

Step 2: Run Care Gap Analyzer​

  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: Review patients with open or overdue gaps​

  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: Review the Patient Timeline and supporting 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 care gap results​

  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 standalone recipe you can reuse in other workflows.

Create a patient cohort from the Assistant​

When to use on its own: When you know the clinical population but don't want to manually build detailed filters.
Features involved: Assistant, Cohort Builder, patient search and filtering, saved cohorts.
Edge cases / limitations: A zero-patient result may mean the data is missing, not that the population doesn't exist. Cohorts should be reviewed before regulatory, trial, or operational use.
Value: Moves you from question to reusable patient population quickly.

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.