Analytics must be enabled for your account to receive this
data. Contact us to get
started. Overview
Care Gaps automatically identifies missing or incomplete care for patients based on HEDIS quality
measures. The system analyzes patient data to determine whether recommended screenings, preventive
care, and treatments have been completed according to evidence-based guidelines.
Care gaps are represented as MeasureReport resources that capture the results of quality measure
calculations, including population membership (initial population, denominator, numerator) and
supporting evidence used in the calculation.
When clinical data becomes available in our system for a patient, care gap evaluation runs on the next
analytics cycle (typically within about 30 minutes). Data may arrive through a
Network Query or
real-time patient notifications such as ADTs. Later cycles keep re-analyzing your
patient population to find opportunities to improve care quality and close gaps in care delivery.
Identifying Care Gaps
A care gap exists when a patient:
- Is in the initial population (count = 1)
- Is in the denominator (count = 1)
- Is NOT in the denominator exclusion (count = 0)
- Is NOT in the numerator (count = 0)
Your organization wants to know which patients are overdue for a mammogram. The system would:
- Find all patients assigned female at birth (initial population)
- Narrow to those aged 40–74 (denominator)
- Remove patients with a bilateral mastectomy or other qualifying exclusion (denominator exclusion)
- Check whether each remaining patient had a mammogram in the past two years (numerator)
Any remaining patient with a numerator of 0 is flagged as a care gap — a patient who is eligible, not excluded, and has
not yet received the recommended screening.
This is a representative example of how the system works.
We’ve excluded other qualifying logic to highlight the
core denominator/numerator concept — the full BCS-E
specification includes additional eligibility and
exclusion criteria.
Available Measures
The following HEDIS measures are currently supported, organized by clinical category.
The measures below reflect the full HEDIS measure set
published by NCQA. If you need a custom measure
implemented, get in touch with us
directly. Access/Availability of Care
| Measure | Code |
|---|
| Adults Access to Preventive/Ambulatory Health Services | AAP |
| Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics | APP |
| Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment | IET |
| Prenatal and Postpartum Care | PPC |
Effectiveness of Care
Behavioral Health
| Measure | Code |
|---|
| Diagnosed Mental Health Disorders | DMH |
| Diagnosed Substance Use Disorders | DSU |
| Follow-Up After Emergency Department Visit for Substance Use | FUA |
| Follow-Up After Hospitalization for Mental Illness | FUH |
| Follow-Up After Emergency Department Visit for Substance Use | FUI |
| Follow-Up After Emergency Department Visit for Mental Illness | FUM |
| Pharmacotherapy for Opioid Use Disorder | POD |
| Adherence to Antipsychotic Medications for Individuals With Schizophrenia | SAA |
| Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia | SMC |
| Diabetes Monitoring for People With Diabetes and Schizophrenia | SMD |
| Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications | SSD |
Care Coordination
| Measure | Code |
|---|
| Advance Care Planning | ACP |
| Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions | FMC |
| Transitions of Care | TRC |
Cardiovascular Conditions
| Measure | Code |
|---|
| Controlling High Blood Pressure | CBP |
| Cardiac Rehabilitation | CRE |
| Persistence of Beta-Blocker Treatment After a Heart Attack | PBH |
| Statin Therapy for Patients With Cardiovascular Disease | SPC |
Diabetes
| Measure | Code |
|---|
| Blood Pressure Control for Patients With Diabetes | BPD |
| Eye Exam for Patients with Diabetes | EED |
| Glycemic Status Assessment for Patients With Diabetes | GSD |
| Kidney Health Evaluation for Patients With Diabetes | KED |
| Statin Therapy for Patients With Diabetes | SPD |
Musculoskeletal Conditions
| Measure | Code |
|---|
| Osteoporosis Management in Women Who Had a Fracture | OMW |
| Osteoporosis Screening in Older Women | OSW |
Overuse/Appropriateness
| Measure | Code |
|---|
| Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | AAB |
| Risk of Continued Opioid Use | COU |
| Use of High-Risk Medications in Older Adults | DAE |
| Deprescribing of Benzodiazepines in Older Adults | DBO |
| Potentially Harmful Drug-Disease Interactions in Older Adults | DDE |
| Use of Opioids at High Dosage | HDO |
| Use of Imaging Studies for Low Back Pain | LBP |
| Non-Recommended PSA-Based Screening in Older Men | PSA |
| Use of Opioids from Multiple Providers | UOP |
| Appropriate Treatment for Upper Respiratory Infection | URI |
Prevention and Screening
| Measure | Code |
|---|
| Chlamydia Screening | CHL |
| Care for Older Adults | COA |
| Lead Screening in Children | LSC |
| Oral Evaluation, Dental Services | OED |
| Topical Fluoride for Children | TFC |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | WCC |
Respiratory Conditions
| Measure | Code |
|---|
| Asthma Medication Ratio | AMR |
| Appropriate Testing for Pharyngitis | CWP |
| Pharmacotherapy Management of COPD Exacerbation | PCE |
Measures Reported Using Electronic Clinical Data Systems
| Measure | Code |
|---|
| Follow-Up Care for Children Prescribed ADHD Medication | ADDE |
| Adult Immunization Status | AIS-E |
| Metabolic Monitoring for Children and Adolescents on Antipsychotics | APM-E |
| Unhealthy Alcohol Use Screening and Follow-Up | ASF-E |
| Breast Cancer Screening | BCS-E |
| Blood Pressure Control for Patients With Hypertension | BPC-E |
| Cervical Cancer Screening | CCS-E |
| Childhood Immunization Status | CIS-E |
| Colorectal Cancer Screening | COL-E |
| Documented Assessment After Mammogram | DBM-E |
| Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults | DMS-E |
| Depression Remission or Response for Adolescents and Adults | DRR-E |
| Depression Screening and Follow-Up for Adolescents and Adults | DSF-E |
| Follow-Up After Abnormal Mammogram Assessment | FMA-E |
| Immunizations for Adolescents | IMA-E |
| Postpartum Depression Screening and Follow-Up | PDS-E |
| Prenatal Depression Screening and Follow-Up | PND-E |
| Prenatal Immunization Status | PRS-E |
| Social Need Screening and Intervention | SNS-E |
Risk Adjusted Utilization
| Measure | Code |
|---|
| Acute Hospital Utilization | AHU |
| Emergency Department Visits for Hypoglycemia in Older Adults With Diabetes | EDH |
| Emergency Department Utilization | EDU |
| Hospitalization Following Discharge From a Skilled Nursing Facility | HFS |
| Hospitalization for Potentially Preventable Complications | HPC |
| Plan All-Cause Readmissions | PCR |
Utilization
| Measure | Code |
|---|
| Antibiotic Utilization for Respiratory Conditions | AXR |
| Well-Child Visits in the First 30 Months of Life | W30 |
| Child and Adolescent Well-Care Visit | WCV |
Getting Started
If the Analytics Platform is enabled for your account, care gap results are available through the
API and Dashboard as each analytics cycle completes.
Accessing via API
Care gap results are available through these endpoints:
These endpoints return FHIR Bundle resources. Each bundle includes a Patient entry, a
MeasureReport, and a Parameters resource with supporting calculation details.
Additional Information
For more information about working with patient data, see the data analytics
documentation.
