Care Gaps

Automated identification of missing or incomplete care based on HEDIS quality measures.

Analytics must be enabled for your account to receive this data. Contact us to get started.

Overview

Care Gaps automatically identifies missing or incomplete care for patients based on HEDIS quality measures. The system analyzes patient data to determine whether recommended screenings, preventive care, and treatments have been completed according to evidence-based guidelines.

Care gaps are represented as MeasureReport resources that capture the results of quality measure calculations, including population membership (initial population, denominator, numerator) and supporting evidence used in the calculation.

When clinical data becomes available in our system for a patient, care gap evaluation runs on the next analytics cycle (typically within about 30 minutes). Data may arrive through a Network Query or real-time patient notifications such as ADTs. Later cycles keep re-analyzing your patient population to find opportunities to improve care quality and close gaps in care delivery.

Identifying Care Gaps

A care gap exists when a patient:

1. Is in the initial population (count = 1)
2. Is in the denominator (count = 1)
3. Is NOT in the denominator exclusion (count = 0)
4. Is NOT in the numerator (count = 0)

Example: Breast Cancer Screening (BCS-E)

Your organization wants to know which patients are overdue for a mammogram. The system would:

1. Find all patients assigned female at birth (initial population)
2. Narrow to those aged 40–74 (denominator)
3. Remove patients with a bilateral mastectomy or other qualifying exclusion (denominator exclusion)
4. Check whether each remaining patient had a mammogram in the past two years (numerator)

Any remaining patient with a numerator of 0 is flagged as a care gap — a patient who is eligible, not excluded, and has not yet received the recommended screening.

This is a representative example of how the system works. We’ve excluded other qualifying logic to highlight the core denominator/numerator concept — the full BCS-E specification includes additional eligibility and exclusion criteria.

Available Measures

The following HEDIS measures are currently supported, organized by clinical category.

The measures below reflect the full HEDIS measure set published by NCQA. If you need a custom measure implemented, get in touch with us directly.

Access/Availability of Care

Measure	Code
Adults Access to Preventive/Ambulatory Health Services	AAP
Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics	APP
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment	IET
Prenatal and Postpartum Care	PPC

Effectiveness of Care

Behavioral Health

Measure	Code
Diagnosed Mental Health Disorders	DMH
Diagnosed Substance Use Disorders	DSU
Follow-Up After Emergency Department Visit for Substance Use	FUA
Follow-Up After Hospitalization for Mental Illness	FUH
Follow-Up After Emergency Department Visit for Substance Use	FUI
Follow-Up After Emergency Department Visit for Mental Illness	FUM
Pharmacotherapy for Opioid Use Disorder	POD
Adherence to Antipsychotic Medications for Individuals With Schizophrenia	SAA
Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia	SMC
Diabetes Monitoring for People With Diabetes and Schizophrenia	SMD
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications	SSD

Care Coordination

Measure	Code
Advance Care Planning	ACP
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions	FMC
Transitions of Care	TRC

Cardiovascular Conditions

Measure	Code
Controlling High Blood Pressure	CBP
Cardiac Rehabilitation	CRE
Persistence of Beta-Blocker Treatment After a Heart Attack	PBH
Statin Therapy for Patients With Cardiovascular Disease	SPC

Diabetes

Measure	Code
Blood Pressure Control for Patients With Diabetes	BPD
Eye Exam for Patients with Diabetes	EED
Glycemic Status Assessment for Patients With Diabetes	GSD
Kidney Health Evaluation for Patients With Diabetes	KED
Statin Therapy for Patients With Diabetes	SPD

Musculoskeletal Conditions

Measure	Code
Osteoporosis Management in Women Who Had a Fracture	OMW
Osteoporosis Screening in Older Women	OSW

Overuse/Appropriateness

Measure	Code
Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	AAB
Risk of Continued Opioid Use	COU
Use of High-Risk Medications in Older Adults	DAE
Deprescribing of Benzodiazepines in Older Adults	DBO
Potentially Harmful Drug-Disease Interactions in Older Adults	DDE
Use of Opioids at High Dosage	HDO
Use of Imaging Studies for Low Back Pain	LBP
Non-Recommended PSA-Based Screening in Older Men	PSA
Use of Opioids from Multiple Providers	UOP
Appropriate Treatment for Upper Respiratory Infection	URI

Prevention and Screening

Measure	Code
Chlamydia Screening	CHL
Care for Older Adults	COA
Lead Screening in Children	LSC
Oral Evaluation, Dental Services	OED
Topical Fluoride for Children	TFC
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents	WCC

Respiratory Conditions

Measure	Code
Asthma Medication Ratio	AMR
Appropriate Testing for Pharyngitis	CWP
Pharmacotherapy Management of COPD Exacerbation	PCE

Measures Reported Using Electronic Clinical Data Systems

Measure	Code
Follow-Up Care for Children Prescribed ADHD Medication	ADDE
Adult Immunization Status	AIS-E
Metabolic Monitoring for Children and Adolescents on Antipsychotics	APM-E
Unhealthy Alcohol Use Screening and Follow-Up	ASF-E
Breast Cancer Screening	BCS-E
Blood Pressure Control for Patients With Hypertension	BPC-E
Cervical Cancer Screening	CCS-E
Childhood Immunization Status	CIS-E
Colorectal Cancer Screening	COL-E
Documented Assessment After Mammogram	DBM-E
Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults	DMS-E
Depression Remission or Response for Adolescents and Adults	DRR-E
Depression Screening and Follow-Up for Adolescents and Adults	DSF-E
Follow-Up After Abnormal Mammogram Assessment	FMA-E
Immunizations for Adolescents	IMA-E
Postpartum Depression Screening and Follow-Up	PDS-E
Prenatal Depression Screening and Follow-Up	PND-E
Prenatal Immunization Status	PRS-E
Social Need Screening and Intervention	SNS-E

Risk Adjusted Utilization

Measure	Code
Acute Hospital Utilization	AHU
Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes	EDH
Emergency Department Utilization	EDU
Hospitalization Following Discharge From a Skilled Nursing Facility	HFS
Hospitalization for Potentially Preventable Complications	HPC
Plan All-Cause Readmissions	PCR

Utilization

Measure	Code
Antibiotic Utilization for Respiratory Conditions	AXR
Well-Child Visits in the First 30 Months of Life	W30
Child and Adolescent Well-Care Visit	WCV

Getting Started

If the Analytics Platform is enabled for your account, care gap results are available through the API and Dashboard as each analytics cycle completes.

Accessing via API

Care gap results are available through these endpoints:

• List Care Gaps — paginated care gaps across your organization.
• List Patient Care Gaps — paginated care gaps for one patient.
• Get Care Gap — full care gap Bundle for a specific measureReportId.

These endpoints return FHIR Bundle resources. Each bundle includes a Patient entry, a MeasureReport, and a Parameters resource with supporting calculation details.

Additional Information

For more information about working with patient data, see the data analytics documentation.