Pregnant People - Key Activity 3


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


This key activity involves the following elements of person-centered population-based care: 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 pregnant patients eligible for recommended care through a care gap report or registry. Like registries used to identify patients who require preventive services for chronic diseases, a perinatal care registry can be used to track all perinatal care patients and assist in ensuring their individual prenatal and postnatal care needs are addressed in a timely manner. The registry should be integrated with the practice’s EHR or population health tool. It should include a list of all perinatal care patients by week of gestation, their corresponding perinatal-specific and general preventive care gaps (either due or overdue), and pregnancy risk level. The care team utilizes the perinatal care registry to monitor the completion of necessary services throughout the episode of pregnancy.

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. Most EHRs already have a module that identifies what services are due for each patient. Care gap reports or registries are recommended as a way to monitor the perinatal care population to ensure that pregnant patients receive timely, comprehensive perinatal care.










Rather than put the responsibility of searching through charts or remembering which patients need further preventive care or follow-up on the individual care team member, this key activity demonstrates how the practice can efficiently leverage EHRs for all its patients.

Care gap reports are essential in understanding how well practices are meeting clinical care guidelines for various measures. This awareness supports improvement, consistency and reliability in meeting care guidelines. At the care team level, gap reports focus on due or overdue labs, screenings, or other interventions for patients assigned to your care team. 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.
  • Remind providers of needed orders for a clinical visit.
  • 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 patients assigned to your practice receive timely care. This approach reduces missed or delayed diagnoses; for example, supporting patients completing gestational diabetes (GDM) screening during the recommended interval avoids delays in GDM treatment. At a systems level, this reduces the burden on the healthcare system by preventing more severe health issues in the future.

For pregnant people, care gap reports can identify patients who are due for regular or infrequently required screenings in accordance with clinical care guidelines, including guidelines that may be established by specific payors. Cervical cancer screening and immunization needs are some examples. Other preventive and maintenance services are noted in the resource Pre-Visit Planning – Gaps in Care Tool.

Many patients experience barriers in accessing care due to structural and individual racism, homophobia, xenophobia, and other biases that deny 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 for patients 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 used to promote a person-centered approach when designing the care plan, such as conducting visits and outreach in the patients’ preferred language.

Furthermore, care gap reports that segment 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. See Key Activity 6: Develop of Refine and Implement a Pre-Visit Planning Process for more information. This creates an opportunity to identify unmet social health needs and connect patients with relevant resources.

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 they may not 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 registry can be thought of as simply a list of patients sharing specific characteristics that can be used for tracking and management. Both care gap reports and registries should have the capacity to segment patients by relevant variables that indicate the need for specialized care elements or risk factors.

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.
Other relevant HIT capabilities to support and relate to this activity include: prenatal 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 or immunization registry 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 ensure 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 in the California Data Exchange Framework (DxF), which can facilitate data sharing between clinics, managed care plans (MCPs) and other partners.


Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Site director and 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 will work on the EHR and, possibly, the EHR vendor.

As a team, decide what screenings or treatment guidelines are appropriate for your population of focus 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, and consider if there are any other gaps, clinical guidelines, or measures your practice feels important to prioritize.

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

Important resources:


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.
Leveraging technology for automation: Each EHR is different, but they generally offer guidance or support on developing care gap reports. In the absence of automatic reports, it may be necessary to engage other staff with the capacity to use other reporting software to develop reports from EHR data.

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 test was performed, if known or if applicable, the previous results, and the type of test 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 refusal of prior screenings.
  • Data on any other characteristic, including insurance data, that could pose a barrier to completing screening.


3. Standardize the data format.

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

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. Develop workflows to support improved patient screening and preventive care completion rates.

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

Identify staff members responsible for the ongoing running and review of care gap reports. Formalize workflow to integrate care gap data into daily clinical practice. Determine who has access to these reports (medical assistants, providers, care coordinators, etc.).

At the patient level, ensure that 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 practice for recommended pregnancy-related care or testing.

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 postal mail.

In addition, as part of the practice’s pre-planning process, patient care gaps should be reviewed and flagged as part of the daily huddle. See Key Activity 6: Develop or Refine and Implement a Pre-Visit Planning Process for more details.

5. Develop a process for review of gaps at the population level.

Suggested team member(s) responsible: Panel manager.

Set a report frequency to review care gap reports at regular care team meetings or huddles in order to develop a plan for improvement at the population level. This may include an outreach campaign to build community awareness of the importance of prenatal and postpartum care and the availability of easily accessed, affordable prenatal and postpartum services.

One limitation of care gap reports for the perinatal population is that they typically only identify patients who have presented to receive care and received confirmation of pregnancy. Patients who have received a positive pregnancy test result within emergency departments, urgent care, or freestanding family planning clinics will not show up within an organization’s care gap report for timely prenatal care. Due to the sensitivity of pregnancy-related services, when considering population-level concerns, patient confidentiality is paramount.

6. 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.