What are Care Gaps/Health Maintenance Reminders?

Question: “Care Gap” alerts appear in my patient’s Storyboard, sometimes related to care I do not provide. What are these and how do I respond to them?

Context: Care Gaps and Health Maintenance Reminders are clinical decision supports in Connect Care that monitor patient characteristics and experiences, then match them to evidence-based preventive care or chronic disease management guidelines in order to recommend actions that may improve care. The underlying algorithms have been adapted to and validated for Albertans. 

Care Gap alerts can appear in the patient’s Storyboard (leftward column in an opened chart, “Care Gaps” section), in the Plan of Care tab of the "Chart Review" activity, or in the "Health Maintenance" activity (global search for "maint" works well). 

  • Example: A diabetic patient's demographics and history trigger an alert indicating that a diabetic foot exam is due (Alberta guidelines call for yearly foot exams for those on the diabetes register).
A Care Gap alert flags possible mismatches between evidence-informed care and a patient's current experience. Connect Care chart content is compared to patient-specific health maintenance plans. Missing or inaccurate information (e.g., incomplete problem, medication or lab results) can lead to false positive, or false negative, alerts.

Answer: Connect Care clinical oversight elected to make Care Gap information available to all providers, irrespective of specialty or context (e.g., outpatient vs. inpatient). This promotes opportunistic preventive care, where important gaps (e.g., immunization needs) can be addressed wherever patients interact with the health care system. Patients most in need of preventive care may not, for example, have a primary care provider.

When a possible Care Gap is identified, providers have several options to address it. The alerts are "passive" and can be left for other providers to attend to. Alerts can be acknowledged but deferred (e.g., adding completion date, Postpone, Discontinue, or entering a date for Follow-Up). Finally, patient's health maintenance plans can be adjusted or deactivated (e.g., not applicable for reason of compassionate care).