Module 9 · Population Health Intelligence · 9.4
Care Gap & Guideline Intelligence
Guideline requirements evaluated prospectively across the population — each open gap is a member-level actionable instance. Same requirement IDs as D5 adherence, opposite temporal stance: D5 scores retrospectively what was done; this lists what is due.
Refresh cycle as-of 5 Oct 2027Gap ledger · 12,416 open high-yield instances
| Gap | Source | Class | Open | Notes |
|---|---|---|---|---|
| Diabetic retinal screening overdue | ADA 2024 | clinical | 3,809 | = 32% of prevalent T2D; ties exactly to the D8 68% coverage figure — one shared object. |
| Statin indicated, not prescribed | ADA 2024 | clinical | 2,140 | High-yield therapy gap. |
| HbA1c measurement overdue | ADA 2024 | clinical | 1,905 | Feeds RS-2 confidence flags. |
| BP recheck overdue after elevated readingPipeline-pending (Stage F) | ISH 2024 | clinical | 4,562 | Activates when ISH ingestion completes (Stage F); renders pipeline-pending before that. |
| PHQ-2 screening gap in primary care | APA 2023 | clinical | 41% | The systemic gap; shared with the Stage D pattern card. |
| Influenza vaccination due | Population screening standards | screening | seasonal | Seasonal ledger — the new guideline class demonstrated. |