Care Gap Closure & HEDIS

Gap Closure Execution Agent

hitl

Runs multi-channel patient outreach, triggers in-visit gap alerts, generates bulk standing orders with physician sign-off, tracks closure, and submits to payers.

Care ManagerQuality & HEDIS ManagerPatient Services
35–50%
Gap closure rate within 60 days
4x
Care manager capacity per FTE
90%
Patient outreach touched per month
Use Case 1

Multi-Channel Outreach Campaign

Trigger: Prioritized gap list from Gap Identification agent

1.Segment patients by preferred channel and language
2.Personalize messages with patient, provider, and gap context
3.Send first touch (SMS/email/mail/voice)
4.Track opens, clicks, responses
5.Trigger escalation sequence for non-responders
6.Close loop when gap is fulfilled
7.Update gap status and submit to payer

Every open gap gets touched; non-responders surface fast to human care teams.

Use Case 2

Bulk Standing Orders with Physician Gate

Trigger: Eligible gap cohort identified

1.Draft individual standing orders with clinical justification
2.Batch orders for physician review
3.Physician approves, edits, or rejects each order
4.Route approved orders to fulfillment (labs, imaging, pharmacy)
5.Notify patients with scheduling or pickup info

Physicians sign off on dozens of orders in minutes instead of one-at-a-time.

Use Case 3

In-Visit Gap Alerting

Trigger: Patient checks in for appointment

1.Pull patient's open gaps
2.Surface top 2–3 closable gaps to care team on intake screen
3.Auto-populate orders/referrals if provider confirms
4.Update gap status in real time

Care gaps close opportunistically during routine visits.

Integrations

Patient Messaging (Twilio, Relatient, Luma Health)
EHR Order Entry (Epic, Cerner, athenahealth)
Mail Fulfillment (FIT kits, reminder letters)
Payer Quality Submission Portal
Care Management Platform
Slack / Teams (care team alerts)

Industries

healthcare

See It In Action

A sample conversation with this agent

Launch outreach for the 487 patients with open colorectal cancer screening gaps.
Launching now. Segmenting by preferred channel: 312 SMS-first (with email fallback), 142 mail-preferred (older cohort), 33 flagged for phone by care manager. SMS messages are personalized with patient name, provider name, and a scheduling link. Non-responders get a second touch at 5 days, third at 12 days. Patients who opt for at-home FIT kits get kits mailed with tracking and prepaid return. I'll give you a daily burn-down of closure rate, response rate, and non-responders needing escalation.
Can you auto-generate standing orders for the mammogram gaps?
I can draft them, but they need a physician sign-off before I act. Here's the plan: I'll pull the 164 patients with open mammogram gaps meeting age and risk criteria, draft individual standing orders with patient name, clinical justification, and order details, and queue them for Dr. Chen as batch sign-off. Once she signs, I'll route orders to the imaging center and send patients scheduling links. She keeps a reject-any button on each order. Want me to proceed with drafting?
Martha Chen didn't respond to three SMS reminders about her eye exam.
Escalating her to care manager review. She's tier-2 risk with uncontrolled diabetes, so the eye exam matters clinically. I'm adding her to Sarah's worklist with full context: 3 SMS sent (no response), last eye exam 18 months ago, nearest in-network ophthalmologist, her preferred language (Spanish), and typical call time based on her past engagement. Sarah can do a warm call and offer transportation if that's the barrier.