Children - Key Activity 3


Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; address social needs.


This foundational activity provides detailed guidance on how to reliably and efficiently develop and use a regularly updated list of all patients eligible for recommended or standard screenings or interventions through a care gap report or registry.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and protocols and the care a patient has actually received. Rather than put the responsibility on the individual care team member for searching through charts or remembering which patients need further preventive care or follow-up, this key activity provides guidance for how the practice can efficiently leverage electronic health records (EHRs) and other applications or technical approaches for all its patients.

Care gap reports are essential for practices to understand and continually improve consistency and reliability for meeting guidelines for preventive care. At the care team level, care gap reports focus on gaps for patients assigned to your care team and help your team understand which patients you are responsible for. These lists can be used to:

  • Support improvements to the pre-visit planning process, develop standing orders, and improve other routine clinical workflows designed to systematically identify and address gaps in care.
  • Prioritize patients for whom care teams should provide proactive outreach and reminders for engaging in care.
  • Support quality improvement efforts with an equity lens.

Actively identifying and acting on care gaps ensures all eligible patients assigned to your practice receive timely screenings and other preventive services.

Many practice patients and families experience barriers in accessing care due to structural and historical racism, homophobia, xenophobia, and other biases that have historically disadvantaged individuals and groups from receiving equitable services. Defining clear criteria and gaps for patients due for specific screenings or preventive services helps to illuminate groups who have not had equitable access. It also combats biases by standardizing expectations for what constitutes quality standards of care for all clients.

Staff can identify potential barriers to patients accessing and engaging in care by using enhanced care gap reports to filter and display the data alongside demographic information, social needs, behavioral health needs, and communication preferences. This information can be incorporated into a person-centered approach when designing the care plan, promoting self-care and other patient engagement activities, such as conducting outreach in the patients’ preferred language. Adopt a trauma-informed approach when designing, testing and implementing interventions to address potential barriers and gaps in care.

Furthermore, care gap reports that segment the data into cohorts based on demographic and other personal information may help the team identify disparities in care, access and outcomes, which can inform improvement efforts.

Care gap reports can be used during pre-visit planning to identify people for whom social needs screening has not yet been completed. This creates an opportunity to identify unmet social health needs and connect patients with resources that address their social needs.

Many EHRs already have a module that identifies what services are due for each patient, while others do not. Where this functionality is available, it may not be configurable to align with the health center’s specific protocol or be able to incorporate outside data. Other options for developing registries include supplemental applications, population health platforms, and freestanding customized databases that draw data from the EHR and other sources. A comprehensive approach to the use of care gap reporting may require multiple modalities.

A registry can be thought of simply as a list of patients sharing specific characteristics that can be used for tracking and management.

Care gap reports may be embedded in electronic health records or made available through other technology channels (see Appendix D: Guidance on Technological Interventions) and are useful both at the individual patient level and aggregated to identify groups of patients to facilitate population-level management through registries.

Figure 4, Figure 5 and Figure 6 provide an example of a care gap report for immunizations and well-child visits.

Other relevant HIT capabilities to support and relate to this activity include care guidelines, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination.

See Appendix D: Guidance on Technological Interventions.

Access to outside data may be a consideration or requirement (e.g., CAIR immunization data, school health data, and data from other practices) as services received outside the health center may be part of compliance. While claims data may be helpful in this regard, lag time may impact its usefulness. Patient-facing applications should be strongly considered to assure they are informed and appreciative of the nature and importance of recommended care. In California, many healthcare organizations are required or have chosen to participate the in California Data Exchange Framework (DxF), which can facilitate data sharing between clinics, MCPs and other partners.


Example Immunization Care Gap Report For An Individual Patient


Example Immunization Care Gap Report For A Panel Of Patients Under Two Years Of Age


Example Wcv Care Gap Report For A Panel Of Patients

Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Panel manager or data analyst. If it is not clear how the report can be produced, this step may involve one or more people from the practice who work on the EHR and, possibly, the EHR vendor.

As a team, decide what screenings or treatment guidelines are appropriate for your patients and prioritize the most important care gaps to run reports on. Start with the core and supplemental measures and any process measures your practice is tracking. Create care gap reports for childhood immunizations and recommended or standard well-child visits based on the Bright Futures periodicity schedule. Consider if there are any other gaps, clinical guidelines or measures your practice feels important to prioritize. See the Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care for a more complete list of preventive and health maintenance guidelines to consider.

Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high risk.

For more information about California immunization requirements for school entry across childhood and adolescence, refer to Shots for School by the California Department of Public Health (CDPH). Initial efforts to develop care gap reports could focus on ensuring that pediatric patients are receiving these required immunizations.

Childhood immunizations are also tracked in the California Immunization Registry (CAIR). CAIR can link into your EHR to provide more up-to-date information for immunizations your patients received at community pharmacies or other health facilities. See Key Activity 2: Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations for other tips on implementing these protocols.

2. Build the report.

Suggested team member(s) responsible: Data analyst.

Determine whether the EHR has an existing report or one that can be modified to fit the inclusion criteria. You should talk to staff who are familiar with the electronic record; in some cases, it may be necessary to consult with the EHR vendor to confirm this information and how to run the report.

The care gap format should include:

  • Criteria for inclusion in the report.
  • The overall compliance rate for the care gap being measured.
  • All patients eligible for the screening and their addresses and phone numbers.
  • The last date the screening or service was provided (if known or if applicable), the previous results, and the type of assessment used.
  • Preferred method of communication (e.g., phone, email, text).

Reports should be able to display and/or disaggregate the data based on:

  • Race, ethnicity and language (REAL) as well as sexual orientation and gender identity (SOGI).
  • Any known social or behavioral needs.
  • Communication preferences or other preferences that would inform the screening modalities offered, such as documented declination of prior screenings.
  • Data on any other characteristic, including insufficient insurance coverage, that could pose a barrier to completing screening.


3. Standardize the data format.

Suggested team member(s) responsible: Panel manager and care team.

Standardizing the data format and where it is entered is critical to ensuring accuracy in the resultant report. Once you know that a report can be produced, understand the specific data elements that are needed to produce the reports.

Document how each data element must be entered into the EHR in order to populate the fields needed for reporting. In some cases, data on completion of screening must be entered by hand (e.g., when the test is performed by a lab that does not communicate with the legacy EHR). Doing this will require a decision on the part of the practice as a whole and may require staff training and reinforcement on an ongoing basis. Where issues or apparent confusion are identified, regular discussion at team huddles or staff meetings will help in maintaining a standard approach.

Tip: Assign responsibility for the initial review of the reports to confirm data integrity.

4. Use the care gap reports in service to other workflows and improvement activities (e.g., assess and improve reliability in meeting well-child visit recommendations).

Suggested team member(s) responsible: Panel manager or data analyst.

A few examples include:

  • At the patient level, the care gap report can be used for or linked with reminders or alerts for clinicians, as well as for sending reminders to patients who need to come into the clinic for screening or follow-up.
  • Depending on communication preferences that have been expressed by patients, the patient care gap report may be exported to an automated reminder system that can trigger reminders by phone, text, email or mail.
  • As part of the practice’s preplanning process, patient care gaps could be reviewed as part of the daily huddle. See Key Activity 5: Develop or Refine and Implement a Pre-visit Planning Process for more details.



Example Population Care Gap Report On Immunization Status

5. Monitor the care gap report for accuracy and completeness.

Suggested team member(s) responsible: Panel manager or data analyst.

It is critical to have bidirectional feedback with the practice’s care team about any real or potential errors in the care gap report, such as:

  • Errors in how the data is entered compared to what is required under the new standardized data format.
  • Patients who are eligible for and due for screening who are missing from the report.
  • Patients who have recently been screened who are still listed as due for a screening.

Errors should be investigated through a chart review. If errors in the report specifications are discovered, the care gap report or process for producing the report should be modified. If the issue is incorrect documentation, staff training and reinforcement of documentation standards will be required.

Additional consideration for sustainability: Ensure there is an internal process for updating the criteria included in the EHR for care gap reports as clinical guidelines change.