Care Insights API · Gaps in Care
Close the gap while the patient is still in the room
Care Insights runs digital quality measure (dQM) logic against the live FHIR record and puts open gaps in care in front of the clinician as HL7 CDS Hooks cards. It is a standalone API: no EHR replacement, no change of quality vendor, and no CQMsolution license required.
- Chart opensA patient-view hook sends the patient context to the DHIT gateway.
- dQM logic runsMeasure logic evaluates the patient’s current FHIR record.
- Card appearsOnly real, open gaps. Try clicking Order FIT kit.
How Care Insights works, step by step
The chart opens in your EHR, the measure work runs on the DHIT hosted service, and the result comes back into the chart the clinician already has open.
In your EHR
Hosted by DHIT
Back in your EHR
1 Trigger
EHR
In your EHR
A clinician opens the patient’s chart, which fires the CDS Hooks patient-view hook.
2 Request
CDS Hooks gateway
Hosted by DHIT
The EHR securely sends patient context and available FHIR® data to the DHIT gateway.
3 Evaluation
Care Insights engine
Hosted by DHIT
dQM logic checks the patient’s current FHIR record against each quality measure.
4 Insight
Care Insights engine
Hosted by DHIT
The engine finds open gaps: measures the patient qualifies for but has not yet satisfied.
5 Delivery
EHR
In your EHR
Actionable CDS cards appear in the clinician’s workflow, like “Patient overdue for A1c test.”
6 Action
Clinician
In your EHR
The provider closes the gap before the patient leaves the room.
Built on FHIR® and HL7® CDS Hooks
Three moments it can fire
Scheduling
appointment-book
When a visit is booked, so staff know what the patient is due for before they arrive.
Chart open
patient-view
When a clinician opens the chart, the moment shown in the steps above.
Encounter start
encounter-start
When the visit begins, so the gaps are in front of the care team from rooming on.
Gaps it can surface
Any measure in the engine can raise a card. A few common ones, with the card the clinician would see:
CMS130
Colorectal cancer screening
No colonoscopy, FIT, or FIT-DNA on record in the lookback period.
“Colorectal cancer screening is overdue”
CMS122
Diabetes monitoring
A patient with diabetes has no A1c result recorded this year.
“Patient overdue for A1c test”
CMS165
Blood pressure control
A hypertensive patient’s most recent reading is at or above 140/90.
“Blood pressure not at goal: recheck and follow up”
CMS117
Childhood immunizations
A child is missing doses that are due before their second birthday.
“Immunizations due: review the schedule”
Same gap, two very different outcomes
Report after the fact
Visit ends
Quarter closes
Report runs
Outreach call
Patient may not come back
Care Insights
Chart opens
Card appears
Gap closed in the visit
One engine, two surfaces
Care Insights is its own API. If you also run CQMsolution, your point of care gaps and your reported numbers come from the same engine and agree.
After the period
CQMsolution
eCQMs for MIPS, ACO, and UDS reporting.
DHIT measure engine
One set of certified CQL logic
During the visit
Care Insights
dQM logic on live FHIR data, as CDS Hooks cards.
Who it moves the numbers for
EHR vendors§170.315(j)(20)Real time quality in your product without building measure logic, and a practical use case for the HTI-4 CDS Hooks client criterion.
ACOsAPP Plus eCQMsGaps closed in the visit never become lost shared savings points.
FQHCsUDS Tables 6B and 7Clinical measures move during the year, not after it.
MIPS groupsQuality categoryMany measures have HEDIS counterparts that shape payer contracts and Star Ratings.
Why DHIT builds this
Most vendors do quality reporting or interoperability. Gaps at the point of care need both, and we have spent decades on both.
~15
years of clinical quality measure calculation and reporting
25+
years of healthcare interoperability work
ONC
extensive Health IT Certification experience
FHIR®
and HL7® implementation expertise, building tools that extend what an EHR can do
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.
Does Care Insights use eCQM logic or dQM logic?
dQM logic. An eCQM is written against the QDM data model and reported as QRDA after the period closes. A digital quality measure is the same measure expressed natively in FHIR, which is what makes it possible to run against a live patient record during the visit. Our eCQM to dQM transition guide covers the timeline.
Does our EHR need to support CDS Hooks?
Yes, CDS Hooks is how the gaps reach the clinician. The HTI-4 certification criterion §170.315(j)(20) certifies an EHR as a CDS Client: registering with a decision support service, authenticating to it, firing the workflow trigger, and rendering the cards that come back.
Do we need CQMsolution to use Care Insights?
No. Care Insights is its own API. It is built on the same quality measure engine as CQMsolution, so running both means your reported numbers and your point of care gaps agree, but you can keep whatever you use for MIPS, ACO, or UDS reporting today.
Is this the same as Da Vinci DEQM Gaps in Care Reporting?
No. The Da Vinci Data Exchange for Quality Measures (DEQM) implementation guide defines Gaps in Care Reporting as an exchange between providers and payers. Care Insights works at the point of care, inside the EHR. We are evaluating how DEQM gaps in care reporting extends our quality products.
DHIT WHITE PAPER
Closing Gaps in Care at the Point of Care
Care Insights · 2026
Go deeper than the diagram
The white paper covers the architecture in detail, what runs in the EHR and what DHIT hosts, and how FHIR, CDS Hooks, and dQMs fit together.