The gap closer.
A quality score is built one patient at a time. So is a risk score. Most people who are judged by those numbers have never seen how they are made.
Here is one patient, one visit, and one year. Plan the visit. Run the year. Then see the whole panel.
- Type 2 diabetes, with kidney disease
- High blood pressure
- Depression, on treatment
It is March. She is here because her refill ran out. Last year, every one of her conditions was in the chart. This year, none of them are yet.
Open for her this year
- Blood pressure in controlLast reading of the year below 140/90Open148/92 in January
- Diabetes in controlLast A1c of the year below 8. No test counts as not in control.Open8.4 in January
- Diabetic eye examA recent exam, with the result in the chartOpenNone on file
- Colon cancer screeningUp to date for her ageOpenOverdue
- Diabetes with kidney complications
- Chronic kidney disease, stage 3a
- Major depression, moderate
Plan the visit.
Pick what happens. Your minutes and your team’s minutes are separate, and both run out. Then run her year and see what counted.
A fifteen-minute visit, after hello and the refill she came for.
Medical assistant, nurse, and front desk, across her day.
A gap is a person.
Every open gap is someone who didn’t get something they were due. The score is how we count them, not the reason to close them.
Done means it reached the chart.
An exam with no report, a kit on a counter, a recheck nobody booked. The care can happen and still not count. Closing the loop is the job.
Write down what is true.
Recapture is not gaming. It is writing down, every year, the conditions a patient still has, with the evidence beside them. Nothing more, nothing less.
More in Value-based care, explained without a single buzzword and MEAT, when an auditor walks in. The patient, the practice, and the numbers on this page are invented. The rules are real in shape: control measures count the last result of the year, a missing test counts as not in control, and a risk score only counts conditions documented that year.