Preventive Care - Key Activity 3


Use Care Gap Reports or Registries to Identify All Patients Due for Cancer Screening


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


This key activity provides detailed guidance on how to develop and use a continuously updated list of all patients eligible for recommended screenings through a care gap report or registry. Please note that this activity focuses on specific cancer screenings, but many other preventive and maintenance services are needed to provide comprehensive preventive care. See the Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource for a more complete list.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and the care a patient has actually received.

Most EHRs already have a module that identifies what services are due for each patient (see examples below). It is important that clinicians address these services and document efforts to communicate with patients about the screening recommendations, barriers that may affect the patient’s ability to undergo the screening, choices for screening available to the patient, and other relevant information in the EHR. Some patients may have elected to pursue screening through another provider. For example, a person may have obtained a mammogram through an outside provider. Efforts should be made to enter the date of screening into the practice’s EHR and to obtain the results of the screening and enter that information into the EHR through an electronically accessed report or scanning the report.



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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 activity provides guidance for how the practice can efficiently leverage electronic health records (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 helps to ensure that all eligible patients assigned to your practice receive timely screenings and other preventive services. For adults with preventive health needs, care gap reports can identify patients who are due for regular or infrequent required screenings in accordance with clinical care guidelines, including guidelines that may be established by specific payors.

Many practice patients 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 and combats biases by standardizing expectations for who is due for what care, providing a starting point for ensuring reliable and equitable access.

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 demographics, social needs, behavioral health needs, and communication preferences. This information can be used to promote a person-centered approach when designing the care plan and promote self-care and other patient engagement activities, such as conducting outreach in the patients’ preferred language. Furthermore, care gap reports that segment the data into cohorts based on demographic and other personal information may help the team identify inequities 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. It also provides an opportunity to identify patients who have undergone screening at another site, obtain screening reports to guide clinical follow up, if needed, and maintain accurate data on patient completion of recommended screening activities.

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.

Care gap reports may be embedded in electronic health records or made available through other technology channels (see Appendix E: 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.
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 age, gender, race, ethnicity and language.

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 E: 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 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 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: 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.

For adults with preventive care needs, use guidance from your cancer screening protocols to build care gap reports for all patients eligible and due for colorectal cancer, breast cancer and cervical cancer screening. Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high-risk. You can build reports across different risk states, such as identifying those with a higher risk for colorectal cancer because of their family history of colorectal cancer, a personal history of inflammatory bowel disease, or a personal history of colorectal polyps.

Generating a report within the EHR is much more complicated for colorectal cancer screening because there is more than one test and more than one frequency of repeat testing. It is less complicated for breast and cervical cancer screening because each screening (at this stage) has one test and one frequency.

For colorectal cancer screening, it is essential to know the type of test last performed to determine the retesting schedule. For example, those who have had a fecal immunochemical test (FIT) test for colorectal cancer are recommended to screen annually, while those who underwent colonoscopy are placed on a 10-year schedule, provided that the test results were negative. In all cases, your cancer screening protocols and the care gap report should be updated to capture the latest recommended frequency for rescreening (see Key Activity 2: Develop or Update the Practice’s Cancer Screening 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 and exclusion 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 and exclusion 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 declination 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 and how it is entered is critical to ensuring accuracy in the report.

Document how each data element must be entered into the EHR 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 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 completion rates.

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

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 adults who need to come into the practice for recommended cancer screening.

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. Several studies and case studies have indicated that personal calls are more effective, so in the absence of a known patient preference, practices should consider personal calls as a strong option.

For adults with preventive care needs, cancer screening reminders can get particularly complicated. See Key Activity 7: Create and Use Clinician Reminders.

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 8: 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 to develop a plan for improvement at the population level. This may include an outreach campaign to build community awareness of the value of screenings and the availability of easily accessed screening services.

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.

See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Evidence base for this activity

Conderino S, Bendik S, Richards TB, Pulgarin C, Chan PY, Townsend J, Lim S, Roberts TR, Thorpe LE. The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control. BMC Med Inform Decis Mak. 2022 Apr 6;22(1):91. doi: 10.1186/s12911-022-01831-8. PMID: 35387655; PMCID: PMC8985310.

Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med. 2009 Feb 23;169(4):364-71.