Guideline question to cohort criteria to care gap

This scenario demonstrates how to ask a guideline-based clinical question, turn the recommendation into cohort or care-gap criteria, create or refine the target cohort, run care gap analysis, and review patients with open or overdue gaps.

Best for: showing how clinical evidence can drive operational quality workflows.

Step 1: Ask a guideline question

1. In the left navigation, go to Agents and Tools > Clinical Guidelines.
2. Ask a guideline question related to the target condition or care topic, for example: "What monitoring is recommended for patients with diabetes?"
3. Review the guideline answer and cited sources.
4. Identify the recommendation that should be translated into an operational care action.
5. Confirm the relevant population, timing, and clinical action described by the guideline.

Step 2: Convert the recommendation into cohort or care-gap criteria

1. Review the guideline recommendation and identify the measurable criteria.
2. Translate the recommendation into patient selection criteria, such as diagnosis, medication, measurement, procedure, visit, age, or date criteria.
3. Identify the care action or missing evidence that should be evaluated as a care gap.
4. Note any criteria that require clinical interpretation before being used operationally.
5. Use the guideline context as the rationale for the cohort or care-gap definition.

Step 3: Create or refine the target cohort

1. In the left navigation, go to Cohort Builder.
2. Create a new cohort using the guideline-informed criteria, or open an existing cohort that should be refined.
3. Review the returned patient population and criteria summary.
4. Apply additional filters if needed to match the guideline population.
5. Review the patient list and exclude patients that should not be part of the cohort.
6. Enter or update the cohort name, description, category, and linked cohort information.
7. Save the cohort.

Step 4: Run Care Gap Analyzer for 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 guideline-informed cohort.
4. Select the care topic, condition, or measure that matches the guideline recommendation.
5. Review the care-gap criteria before running the analysis.
6. Start the care gap analysis.
7. Wait until the care gap job status is Completed.
8. Open the completed care gap results.

Step 5: Review patients with open or overdue gaps

1. Review the patient-level care gap results.
2. Identify patients with open, overdue, missing-evidence, or follow-up-needed gap statuses.
3. Review the explanation for each gap status.
4. Open the patient timeline when clinical context is needed.
5. Review diagnoses, visits, medications, measurements, procedures, and supporting documents.
6. Confirm whether the gap appears valid, resolved, or uncertain.
7. Export the care gap results as CSV if the list should be shared with the quality or care-management team.

Recipe reference

Each stage of this scenario is also a standalone recipe you can reuse in other workflows.

Ask guideline questions and apply findings to a cohort workflow

When to use on its own: When a clinician or analyst needs evidence-based context before defining criteria or reviewing care gaps.
Features involved: Clinical Guidelines, Assistant, Cohort Builder, Care Gap Analyzer.
Edge cases / limitations: Guideline answers support decision-making but do not replace clinical review. Not every recommendation maps cleanly to available patient data.
Value: Helps you connect clinical evidence to operational workflows.

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.