White Paper · Care Insights · 2026
Closing Gaps in Care at the Point of Care
Traditional quality reporting tells you what happened after the patient has left. This white paper shows how the same quality measure logic you already run for reporting can flag open gaps in care inside the EHR workflow, while the provider can still act.
The shift this white paper is about: moving from “Did the patient receive the appropriate care?”, a question you can only answer after the fact, to “Can we help the provider deliver that care before the patient leaves?”
What open gaps in care actually cost
A gap in care exists when recommended, evidence-based care has not been completed: a due preventive screening, an overdue immunization, missing chronic disease monitoring, an outstanding follow-up. Every open gap is a patient who did not get recommended care on time. The financial consequences then show up in every value-based program you report to:
- MSSP and ACO quality scores. Under APP Plus, eCQM performance directly affects shared savings. Unclosed gaps sit in your denominators all year and surface as lost quality points. Our ACO eCQM Reporting Guide covers the reporting side in depth.
- MIPS quality performance. The same measures drive your MIPS quality category, and your payment adjustment.
- UDS clinical tables. For health centers, Tables 6B and 7 reflect exactly these gaps. See the UDS Reporting Guide for how those measures roll up.
- Medicare Advantage Star Ratings and payer contracts. Payers measure the same gaps through HEDIS. Providers who close them during the visit perform better in risk contracts and quality incentive programs.
Most organizations attack these gaps with retrospective reports, chart review, and outreach campaigns after the fact. That work is expensive, and it happens weeks after the moment when closing the gap would have been easy.
Where gaps cluster
Care gaps are not spread evenly across the measure set. They concentrate in a familiar handful of quality measures where the care is recurring and easy to miss:
Chronic disease monitoring
Diabetic patients overdue for A1c testing or eye exams, hypertensive patients without a recent controlled blood pressure reading.
Preventive screenings
Breast, colorectal, and cervical cancer screening measures, where a due date passes quietly between visits.
Immunizations & follow-ups
Missed vaccine series, and follow-up visits or labs that were ordered but never completed.
Each of these is a quality measure your reporting system already calculates. If the logic already knows the patient has an open gap, why does that knowledge only show up in a report at the end of the quarter?
Why EHR reminders have not solved this
Most EHRs have health maintenance reminders, and most clinicians have learned to tune them out. The typical reminder is a static age-and-sex rule: it does not read the full clinical history, it does not follow the actual measure specification, and it fires the same way for a patient who is truly due as for one whose screening happened at an outside facility last month.
Closing gaps reliably at the point of care requires something different: the real quality measure logic, evaluated against the patient’s actual record, delivered inside the workflow at the moment a decision is being made. That is what DHIT built Care Insights to do. It runs quality measure logic against the patient’s live FHIR data in our quality measure engine, and delivers the result into the clinician’s workflow through HL7 CDS Hooks.
Care Insights is delivered as its own API. CQMsolution runs on the same engine, but you do not have to be a CQMsolution customer to use it. The white paper walks through how it works.
What’s inside the white paper
- Why retrospective quality reporting keeps finding gaps too late, and what to do about it
- The complete six-step Care Insights workflow, from chart open to closed gap, inside the EHR
- How FHIR, CDS Hooks, and digital quality measure concepts fit together in one architecture
- A workflow diagram showing what runs in the EHR and what DHIT hosts
- How to position your quality infrastructure for the transition to digital quality measures
Where quality measurement is headed
Point-of-care gap closure is not a side project; it is the direction the whole measurement enterprise is moving. CMS has signaled a multi-year transition from today’s eCQMs toward FHIR-based digital quality measures, and ONC has begun certifying EHRs as CDS Hooks clients under HTI-4. Care Insights runs dQM logic over FHIR and delivers through CDS Hooks, so the same investment that closes a gap during this afternoon’s visit is the one that carries you to the digital quality measure deadlines.
Gaps in Care: Frequently Asked Questions
What is a gap in care?
A gap in care exists when recommended, evidence-based care has not been completed for a patient who qualifies for it: a due preventive screening, an overdue immunization, missing chronic disease monitoring, or an outstanding follow-up. In quality measurement terms, it is a patient who is in a measure’s denominator but has not satisfied its numerator. You may also see the same concept called a care gap or an open gap.
What is the difference between clinical decision support and gaps in care?
They answer different questions. A gap in care is a clinical finding: this patient is due for recommended care that has not happened. Clinical decision support (CDS) is a delivery mechanism: the alerts, recommendations, and guidance an EHR surfaces to clinicians at the moment of care. The two meet when gap identification is delivered through CDS. In Care Insights, quality measure logic finds the open gap, and an HL7 standard called CDS Hooks carries that finding into the clinician’s workflow as an actionable card. Gaps in care are the “what”; clinical decision support is the “how it reaches the provider.”
What is the difference between an eCQM and a dQM, and which does Care Insights use?
They are two expressions of the same measure. An eCQM is a clinical quality measure built for retrospective reporting: the logic is written against the QDM data model and the results are submitted as QRDA files after the reporting period closes. A digital quality measure (dQM) is that same measure expressed natively in FHIR, with the patient data modeled as FHIR/QI-Core resources, so the logic can be run against a live patient record instead of an end-of-year extract. CMS is moving the entire measure enterprise in this direction.
Care Insights runs the dQM form of the logic. That is precisely what makes real-time evaluation during the visit possible: the FHIR quality measure logic in our engine reads the patient’s current FHIR data and returns the open gaps while the provider still has the chart open. Our guide to eCQM requirements and the dQM transition covers the timeline and the standards involved in detail.
Is gap identification based on HEDIS, eCQMs, or dQMs?
Care Insights evaluates patients with digital quality measure (dQM) logic — the FHIR-based version of the same measures you already report on. It is the same measure intent, and largely the same CQL, that CQMsolution calculates as eCQMs for MIPS, ACO, and UDS; the difference is that the dQM form runs against FHIR data in real time rather than against a retrospective extract. Many of those measures also have HEDIS counterparts that payers track, so closing a gap during the visit usually improves the corresponding HEDIS and Star Ratings picture as well. The distinction matters mostly for reporting; for the patient, a closed gap is a closed gap.
Does our EHR need to support CDS Hooks?
CDS Hooks is the delivery standard Care Insights uses. In the HTI-4 final rule, ONC adopted a new certification criterion, 45 CFR §170.315(j)(20) — Workflow Triggers for Decision Support Interventions—Clients, which certifies an EHR as a CDS Client under the HL7 CDS Hooks 2.0.1 (STU 2) implementation guide: registering with a decision support service, authenticating to it, firing the workflow trigger from inside the clinician’s workflow, and rendering the cards that come back.
If you are an EHR vendor, Care Insights gives you a way to add real-time quality intelligence — and a (j)(20) use case — without building measure logic in-house. If you are a provider organization, the practical starting point is a conversation about what your EHR exposes today; the white paper’s workflow diagram shows exactly which pieces run in the EHR and which DHIT hosts.
Do we have to replace our EHR or quality reporting system?
No, and you do not have to change quality vendors either. Care Insights is delivered as an API that plugs into your existing EHR through standard FHIR and CDS Hooks integration, so it adds real-time gap identification to the stack you already have rather than replacing your EHR or your reporting workflow.
Do we need CQMsolution to use Care Insights?
No. CQMsolution and Care Insights are built on the same DHIT quality measure engine, but Care Insights is available on its own: it evaluates dQM logic against your FHIR data and returns gaps through CDS Hooks, whatever you use for MIPS, ACO, or UDS reporting today. If you are a CQMsolution customer, the two fit together nicely. The measures you report on and the gaps you close at the point of care come from one engine and one data foundation. If you are not, Care Insights still works, and it does not require you to move your reporting.
More on quality reporting
Product
CQMsolution
The ONC-certified quality measure engine behind Care Insights: MIPS, ACO, and UDS measures from one data foundation.
Guide
UDS Reporting Guide for FQHCs
Countable visits, multi-table data aggregation, and the move to UDS+ patient-level FHIR reporting.
White Paper
ACO eCQM Reporting Guide
How APP Plus quality reporting and multi-EHR data aggregation come together for Medicare ACOs.
Quality Measure & Interoperability Solutions
Bring quality measurement to the point of care
Talk with the DHIT team about Care Insights: turning the quality measure logic you already report on into real-time recommendations that close gaps in care before the patient leaves.