Closing Care Gaps with EHR Analytics Your Team Will Actually Use

Care gaps like missed mammograms, uncontrolled A1c values, and overdue wellness visits are not just quality metrics. They are revenue left on the table, risk adjustment missed, and patients who drift out of continuity. Your EHR already holds the data to find them. Most clinics never operationalize it.

Define five priority gaps for your panel

Do not try to close every gap at once. Pick five that match your payer mix and patient population: colorectal screening, breast cancer screening, diabetes A1c control, hypertension follow-up, and annual wellness for Medicare patients are common starting points for primary care.

Build a weekly gap list, not a quarterly report

• Run registry reports every Monday for patients with visits in the next two weeks
• Attach gap alerts to the schedule so MA staff can order labs before the visit
• Use portal outreach for patients without upcoming appointments
• Track closure rate by provider to identify who needs template or workflow support

Make closure part of the visit, not an add-on

The most effective clinics embed gap closure into visit templates. A diabetes follow-up template automatically surfaces the last A1c date, flags if screening is overdue, and includes order sets for repeat labs. The provider does not hunt for information. It is already in the workflow.

One clinic in Alberta improved colorectal screening rates from 58% to 74% in six months by adding a pre-visit MA checklist and a single-click order set. No additional staff. No external care management vendor.

Jevrix customers typically see measurable improvements within the first 90 days when implementation follows a structured, role-based playbook. Book a demo to see how this applies to your organization.