Day 3, Population Care, KP Colorado : Care gaps are the currency (and we want to go broke)

Brent Arnold, MD, Colorado Permanente Medical Group

The last day of a shadowing experience is always a little like a graduation – it’s where you’ve slept on what you’ve seen (which is why it’s important to spend more than a day shadowing), and then you watch things come together at the highest level of the health care system, where the patient is.

On day 3, we went to one of Kaiser Permanente’s newest medical offices, in Parker, Colorado, where we shadowed Brent Arnold, MD, who’s an internal medicine specialist that thinks more like a family medicine specialist (in my opinion).

We ended our day meeting with John Merenich, MD, the parent of Colorado HealthTRAC and his team to discuss what we saw and learned.

The Care Gap revolution

The phrase in the title of this post was expressed to me first by Sean Riley, MD, on day 2, and then embellished by Brent. Here, they are identifying care gaps, dissecting them, using them to measure their success as doctors, and working to eliminate them.

The term “care gap” describes any missing recommended care either in prevention of illness or management of chronic conditions. It’s been known for some time that Americans typically receive about 55 % of recommended care (!) the rest have gaps. I don’t see a lot of discussion in non-integrated health care about closing these gaps, or even that they exist. Instead, it’s still the drive to see more patients, to take care of more acute problems (“whatever comes in the door”).

In my visits to Portland and Orange County, I heard about care gaps and closing them a lot, and now at Colorado, I finally had the “a ha” that this has been a slowly building change in thinking, and now it’s a full revolution. It’s happened because of (a) the ability to know about patients in an integrated care system and (b) the ability of patients, nurses, doctors, and the health system to innovate together.

John Merenich verified my “a ha” with what he’s known for a long time, by reciting the mission statement of his team, which is “Deliver Knowledge about Care Gaps and Care Gap Solutions for any Member Population.”  I am not that smart and my ideas are not that unique, after all :).

Here’s what it looks like to me:

Physicians marginal, Teams phenomenal – we learned at our time with this team that the most dedicated physician can probably be 50 % successful in addressing care gaps. There are just too many other places and ways they could be addressed in the practice and health system, and why would a physician not want to take advantage? In a team based model, physician, nurse, medical assistants strategize about the entire problem (people having care gaps) and figure out how to inform patients, how to close care gaps.

Part of every interaction – Brent had 10 years of experience in the hospitality industry before becoming a physician. He said that not addressing care gaps is like “not filling up their tea after it’s half empty.” The drive then, is to think about an interaction as incomplete unless care gaps are addressed. Ask yourself about your last physician visit or interaction with the health system – were you informed about what your care gaps were and how to solve them?

Focusing on those who come in to be seen won’t close care gaps for an entire panel – At Parker Medical Office, Brent tells us how his team is running multiple PDSA cycles to understand how to close care gaps for as many people as possible. He says, “If you focus on only the patients that come in to be seen, you’ll help 100 patients a week, that’s not enough.”

I sat with the desktop medical assistant as she called to tell patients about requested medication refills. In each conversation, care gaps are mentioned – “I see you are due for a mammogram, can we schedule that for you?” I asked what that feels like, to bring up a topic that seems unrelated to the reason for the call. I’m told that mammography is a little bit harder to discuss, mostly because of the perceived discomfort of the procedure itself, but overall, not difficult. They are tracking the response to the messages given via phone, as well as secure e-mail on, to see if care gaps are getting closed. They are.

Kaiser Permanente Parker, Colorado Medical Office

The emergency of the heart attack is being replaced by the urgency of the care gap – The way they organize around them is telling – they created an acronym in their PDSA’s: CLOT, which stands for “CLick, Order, Tell (Inform)” – Click into the population care system to review care gaps, order needed tests, inform the patient. The analogy is a clot to stop the bleeding that comes from care gaps that are unattended to.

Midway through our conversation, Brent says, “I know I’m preventing heart attacks!” And…he’s right. they are:

So the thing that American health care can be so good at, rescue care, emergency care, can be redeployed toward preventive care, to keep people well before they get sick, to save lives.

Watching in the context of patient care

I shadowed Brent and his medical assistant Amanda, as she roomed patients, addressing their care gaps, then with a follow-up as part of the visit by Brent. I’l say that these conversations are not always easy, especially when a patient has not been engaged and may have multiple, potentially life threatening, care gaps.

However, they ask, every time. And they keep asking, because eventually the mammogram does get done, the colon cancer screen is turned in. And even in the asking, the patients say meaningful things about how they see their health and where it’s going – things that would not have been brought up if their care gaps were not brought up – the care gap conversation creates a space for listening to patients, too.

On the last patient that Amanda roomed, we walked out and she said, “This patient didn’t have any care gaps, sorry I couldn’t show you how I handle them this time.” I said I think that’s more of a cause for a congratulations than an apology, and great to learn what it looks like and feels like when patients can be successful in being healthy.

This is the last in the series of posts from my visit to learn about population care in the 21st Century. Thanks a ton to the members, staff, nurses, physicians of Kaiser Permanente Colorado (@KPColorado) for being such willing educators and excellent performers.



Thanks, Ted, for your great posts on population care and closing care gaps. I think a lot about care gaps and how we, as an organization (Group Health) approach this challenge. I feel fortunate to work in an integrated system with good informatics that allow us to see gaps. We also have developed some early approaches to delivering care needs, based mainly on HEDIS (Healthcare Effectiveness Data and Information Set) measures. This is the right work, but there is a long way to go.

When I think about care gaps, I think about risk. Risk of bad things happening to people. Risk of death, heart attack, stroke, infection, hospitalization… We can estimate risk with varying degrees of accuracy, across populations. The evidence isn't great at telling us which of our patients will suffer from an unclosed gap, but at the population level, it starts to make sense.

I have two basic jobs as a primary care doctor. (1) Manage the patient in front of me (either in clinic, on the phone, or emailing me), to respond to their concerns and help them to develop a plan to get or stay healthy. (2) See the risk across all of my patients and do my best to lower that risk, one person at a time.

At the population level, the risk we see is often not today's risk. Data makes its way through systems at variable speeds, and often the information that populates risk models is months old (it may be based on claims, for example). Seeing today's risk today would give us a better chance of preventing unhappy outcomes.

Imagine, for example, if we could match air quality maps in our clinic area with addresses of patients with chronic respiratory disease. Or could we see GPS data on where patients were using their asthma inhalers. We could deploy messages and preventive measures to prevent complications, ER visits, and hospitalizations.

Or what if we could centralized data to bring together pieces of information to help us make predictions about risk. Utilization data (ER and Urgent care visits), diagnostic codes, lab data, and home measures (weights, blood pressures) pulled together into a visually useful heat map could guide my efforts to be more useful to my population (I stole this concept from James Hereford and will keep stealing until I've got a heat map).

One day to the next, the care gap list I consult looks fairly similar. And yet I get surprised by unanticipated events. A beloved patient with a remote stroke history died suddenly last week. A second stroke. The next day, I dug into her chart to be sure I was giving her the best evidence-based care I could. Thanks to a good information system and a great team, she was getting the right care and her measures were all in target ranges. So was this just something that happened? Maybe. Is the evidence on secondary stroke prevention incomplete? Certainly. And was there information we could have known about her risk of another stroke? Of course; her risk of stroke became 100%, and our current risk models didn't pick it up.

How far would this go? I imagine a good heat map telling my primary care team who is at risk of something bad today and further into the future. Beyond known risk (chronic disease) and preventive measures (pap smears, mammograms), a good heat map might help me know about risk from poor diet ("Mr. Jones, the asparagus in your fridge is about to go bad.") or inactivity ("Ms. Finklestien hasn't burned a supplemental calorie in a week; let's connect her with a walking companion.")

Like most busy people, I see what's presented, and often that's whatever is calling loudest. If risk started to show up as a compelling daily visual–the heat map, showing me clearly who is at risk TODAY–my days would be very different, more useful to patients, and more satisfying.

Looking forward to discussing this more!


Thanks for engaging on this issue – you are in as good a position as any physician leader in the U.S. to take the idea of population care to the next level, as Physician Chief of one of the most innovative medical centers in one of the most innovative health systems…

I think the idea of enhanced visualization about the health and risk of a patient panel tailored to the primary care team is really important. Recently, the Garfield Center had a technology demo day about geographic information systems in care delivery – you can imagine the potential for a heat map of a panel's risks combined with a heat map of community risks where those panel member live…

Have you come across some heat map examples that would work for you and your team? Bring them to Portland next week, as we learn about breakthrough innovation, let us definitely continue the conversation with the 40 other physician, nurse (and nurse midwife!) experts.

Feel free to post links to any here and we can also open the floor to comments to anyone who has experience doing this work or has thought similarly,


Ted Eytan, MD