Milestone 16 Summary

Description: Practice uses population reports or registries to identify care gaps and acts to reduce them.

What does success look like?


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Practice does not collect data on care gaps for its population of patients. Practice produces or receives care gap reports but these reports are limited to specific payer or diagnostic groups and do not cover the entire population of patients. Practice produces or receives care gap reports for prevention and chronic conditions/other diagnoses prevalent in the practice’s patient population, but does not yet have a system in place to follow up on each report in order to reduce the gaps. Practice analyzes care gap reports for prevention and chronic conditions/other diagnoses prevalent in the practice’s patient population and has a system in place to regularly act on the data, including outreach to individual patients needing intervention.

Note: numbers are PAT scores

Why is this important?

As health care costs continue to rise, the goal of population health represents a crucial culture shift from treatment-focused care to prevention-focused care.1 As the American population is increasingly affected by obesity and co-morbidities, prevention-focused care can help manage those already diagnosed with chronic conditions, prevent the onset of additional diseases, and reduce the cost that chronic diseases impose on the healthcare system.2 By identifying opportunities to be proactive and incorporating evidence-based preventative services, clinicians can identify trends in their patient population, encourage healthy behaviors, and reduce ED admission rates and long-term health costs. As the system transitions from fee-for-service to value-based reimbursement, screenings, immunizations, and well visit adherence will greatly affect the quality performance rating and reimbursement of a clinical practice.3 Clinician awareness of gaps in patient care creates a joint social responsibility to improve patient outcomes.

With a growing number of data sources and increased technological capabilities, health management is possible at a population level.1 Through a combination of EHR, claims, and registry data, practices can identify patients who are missing important preventative services and can reach out to ensure continuity of quality care. Strategies proven to reduce missed opportunities of care include: automated reminders, flags for providers at point of care, alerts to identify missed opportunities, and clinical decision support systems.2 These processes, combined with the population health features in many EHRs and claims gap reports from insurance companies, provide opportunities to identify and rectify gaps in individual care across patient populations.

Potential Tactics

  • Utilize EHR pop up reminders to appear as part of scheduling modules
  • Use EHR and payer care gap reports
  • Include medical residents’ assessments, not just faculty, for care gap reports in academic settings
  • Use clinical decision support aids such as “ACR Select”

Tools and Resources


What might this look like in practice?

To capture gaps in care, a practice will need to have thorough, accurate and timely records of a patient’s visit and status in the Electronic Health Record (EHR). Using the population health features in an EHR, practices can identify patients who have upcoming or missed appointments, not received certain immunizations, have overdue tests or results out of the normal range. For instance, a report can quickly identify all patients in a provider’s panel whose hypertension is currently non-controlled. These care reports should be run on a automated schedule and reviewed by the care team. From these reports, automatic outreach can be generated to contact the patient to notify them of their status.

EHR alerts can also be linked to the scheduling system so that when a patient calls in to schedule an appointment, clinical staff are notified of the patient’s gaps and can work to schedule any necessary appointments to ensure delivery of these services. In addition, these same alerts can notify the care team at the point-of-care in order to prevent any missed opportunities. Automated outreach and auto-generated reminder services are key in getting entire patient populations into the clinic, at which time the other alerts are key in identifying the gaps.

Practices can learn more about their specific EHR’s population health capabilities and tracking through their EHR vendor. In addition to EHRs, care teams can use claims data reports and disease registries comparisons to identify patients who are in most need of outreach. There are population health software packages available for purchase as well.



  1. Shaljian, M. Nielsen, M. Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood. Patient-Centered Primary Care Collaborative (2013).
  2. Young AS, Chaney E, Shoai R, et al. Information Technology to Support Improved Care For Chronic Illness. Journal of General Internal Medicine. 2007;22(Suppl 3):425-430. doi:10.1007/s11606-007-0303-4.
  3. Healthcare Informatics. Healthcare Informatics Research Report: A Roadmap for Population Health Management (2016).