care-gap-identification

name	care-gap-identification
description	Identify missing or overdue care steps against HEDIS, STAR, USPSTF, and disease-specific quality measures for individual patients or populations. Use when performing care gap analysis, generating patient outreach lists, preparing for quality measure reporting, or supporting value-based care performance improvement.
metadata	{"display_name":"Care Gap Identification","short_description":"Find missing care steps against HEDIS and STAR measures","default_prompt":"Review my care gap and highlight top risks and next actions","version":"1.0.1","tags":["healthcare"],"icon_path":"assets/icon.png"}

Care Gap Identification

Overview

Systematically identify missing, overdue, or incomplete care activities by comparing patient clinical records against evidence-based quality measures and preventive care guidelines. This skill evaluates compliance with HEDIS (Healthcare Effectiveness Data and Information Set), CMS Star Ratings, USPSTF recommendations, and disease-specific protocols to surface actionable care gaps for individual patients or population panels.

When to Use

• Running care gap analyses for patient panels or individual patients
• Preparing for HEDIS or STAR rating measurement periods
• Generating patient outreach lists for preventive services
• Supporting value-based care contract performance
• Identifying gaps before annual wellness visits or chronic care appointments
• Building quality dashboards with gap closure tracking

Required Inputs

Input	Description	Format
Patient clinical record	Diagnoses, procedures, labs, medications, demographics	Structured object
Applicable measure set	HEDIS, STAR, MIPS, or custom measure set	Enum or array
Measurement period	Calendar year or custom date range	Date range
Claims/encounter data	Service dates and codes for completed services	Array
Pharmacy data	Filled prescriptions with dates and days supply	Array

Methodology

Step 1: Measure Applicability Determination

Identify which quality measures apply based on patient demographics and conditions:

1. Evaluate age, sex, and insurance type against measure denominators
2. Check active diagnoses for disease-specific measures (diabetes, hypertension, depression)
3. Apply exclusion criteria (hospice, terminal illness, denominator exclusions)
4. Generate the applicable measure list for this patient

Step 2: Service History Evaluation

For each applicable measure, check if the required service has been completed:

• Screenings: Was the test performed within the required interval?
• Immunizations: Is the vaccine series complete and current?
• Chronic disease management: Were required labs and visits completed?
• Medication adherence: Does PDC (Proportion of Days Covered) meet threshold?
• Follow-up care: Were post-event follow-ups completed within required timeframes?

Step 3: Gap Classification

Classify each gap by type and urgency:

Gap Type	Description	Example
Overdue screening	Preventive service past due	Mammogram overdue by 8 months
Missing lab	Required monitoring lab not done	HbA1c not done in 12 months for diabetic
Medication gap	PDC below threshold or Rx not filled	Statin PDC at 72% (threshold 80%)
Missing follow-up	Required follow-up not completed	No 7-day follow-up after MH hospitalization
Immunization due	Vaccine not current	Pneumococcal vaccine not administered for 65+
Assessment missing	Required screening tool not administered	PHQ-9 not done for depression patient

Step 4: Priority Scoring

Score each gap by clinical impact and measure weight:

Priority Factors:

• Clinical urgency (immediate health impact vs. long-term prevention)
• Measure weight in quality programs (triple-weighted STAR measures carry more impact)
• Time sensitivity (approaching measure close date, overdue duration)
• Patient risk level (high-risk patients have amplified gap impact)
• Contractual significance (tied to value-based payment)

Step 5: Intervention Recommendation

For each identified gap, recommend closure actions:

• Specific service needed with CPT/HCPCS code
• Preferred provider or care setting
• Patient outreach method (phone, portal message, mail)
• Scheduling guidance (combine with upcoming visit if possible)
• Documentation requirements for measure credit

Output Specification

The output includes:

patient_summary: demographics, risk_level, payer, applicable_measure_count

applicable_measures: measure_id, measure_name, domain (preventive/chronic/behavioral/medication), denominator_criteria_met, exclusions_evaluated

identified_gaps: measure_id, measure_name, gap_type, gap_description, last_completed_date (if ever), due_date, overdue_by, priority_score, clinical_urgency, closure_action with CPT code and service description, estimated_effort

gap_summary_by_domain: domain, total_measures, gaps_found, gap_rate

closed_measures: measures where criteria are met (for completeness tracking)

outreach_recommendations: patient contact preferences, suggested outreach message, scheduling recommendations

Analysis Framework

Key HEDIS/STAR Measures

Measure ID	Measure Name	Service Required	Frequency
BCS	Breast Cancer Screening	Mammography	Every 2 years, age 50-74
CCS	Cervical Cancer Screening	Pap/HPV test	Every 3-5 years, age 21-64
COL	Colorectal Cancer Screening	Colonoscopy/FIT/Cologuard	Per modality schedule, 45-75
CDC-HbA1c	Diabetes: HbA1c Testing	HbA1c lab	Annual
CDC-Eye	Diabetes: Eye Exam	Retinal exam	Annual
CDC-Kidney	Diabetes: Kidney Health	eGFR + uACR	Annual
CBP	Controlling High Blood Pressure	BP reading under 140/90	Annual
SPC	Statin Use in CVD	Statin therapy + PDC 80%+	Ongoing
FUH	Follow-Up After MH Hospitalization	Outpatient visit	7 and 30 days post-discharge

Medication Adherence Measures (Triple-Weighted in STAR)

• Diabetes medications: PDC threshold 80%
• RAS antagonists (hypertension): PDC threshold 80%
• Statins (cholesterol): PDC threshold 80%

PDC = (Total days covered by fills in period) / (Days in measurement period) x 100

Examples

Input: 58-year-old female with type 2 diabetes, hypertension, on metformin and lisinopril. Last HbA1c: 14 months ago. Last mammogram: 3 years ago. Last eye exam: 2 years ago. Statin not prescribed despite ASCVD risk score >20%.

Gaps Identified:

1. CDC-HbA1c: OVERDUE (14 months, annual required) — Priority: HIGH. Action: Order HbA1c lab
2. BCS: OVERDUE (3 years, every 2 years required) — Priority: HIGH. Action: Schedule mammogram
3. CDC-Eye: OVERDUE (2 years, annual required) — Priority: MEDIUM. Action: Refer to ophthalmology
4. SPC: NOT MET (statin not prescribed, ASCVD risk >20%) — Priority: HIGH. Action: Prescribe statin therapy
5. CDC-Kidney: UNKNOWN (no eGFR/uACR on file) — Priority: MEDIUM. Action: Order renal panel with uACR

Guidelines

1. Apply exclusions before flagging gaps — ensure patients are truly in the measure denominator
2. Check supplemental data sources — patients may have completed services outside the primary system
3. Combine gap closure with existing visits — maximize efficiency by bundling services
4. Prioritize triple-weighted measures for STAR rating impact
5. Track gap closure rates over time to measure program effectiveness

Validation Checklist

• All applicable measures are identified based on demographics and conditions
• Exclusion criteria are properly evaluated before flagging gaps
• Gap dates are calculated correctly against measurement period requirements
• Priority scoring reflects both clinical urgency and quality program impact
• Closure actions include specific CPT/HCPCS codes and service descriptions
• Medication adherence gaps include current PDC calculations
• Output distinguishes between "never done" and "overdue" gaps

HIPAA Compliance Notes

• Care gap data involves PHI and must be processed within BAA-covered systems
• Patient outreach for gap closure must comply with communication preferences and consent
• Population-level gap reports should be de-identified for quality improvement analysis
• Share gap data with contracted providers only under appropriate data use agreements
• Medication adherence data sourced from pharmacy claims requires appropriate authorization chains