Providers can identify all care gaps (screenings, labs, follow-ups, adherence) in one unified platform.
Automated routing, reminders and care manager tasks turn identified gaps into completed actions.
Improved quality metrics, fewer complications and stronger outcomes support value-based contracts and regulatory compliance.
Patients with chronic disease often miss recommended screenings, labs, or follow-up visits—creating hidden risk and poor outcomes.
blueBriX aggregates EHR data, claims and care-plan information to spotlight gaps (e.g., overdue HbA1c, missed nephropathy screen) and presents them on a unified dashboard for action.
Know moreOnce a gap is identified, follow-up work often lives outside the EHR: manual lists, phone calls, disparate systems—leading to low closure rates.
blueBriX triggers automated outreach (SMS/email), schedules required visits or labs, assigns care-manager tasks and tracks completion—all within the same platform.
Know moreChronic-care gaps translate into quality-measure penalties, lower ratings and weaker value-based performance—but many providers struggle to tie their operations to these metrics.
blueBriX maps care-gap closures to quality scores (HEDIS, Star Ratings, CCM outcomes) and value-based contract targets—giving providers a clear view of how gap-management drives performance.
Know moreChronic disease management often involves specialists, primary care, home health and social services; coordination breaks down, and gaps persist.
blueBriX provides a shared care-plan space and coordination hub where primary care, specialists, home health and community partners access the same patient-profile and tasks—closing the loop across settings.
Know moreLearn how industry leaders are adopting this approach
Let's get started!Addressing care gaps for chronic disease isn’t just clinically smart—it aligns directly with regulatory expectations such as Chronic Care Improvement Program (CCIP) under Centers for Medicare & Medicaid Services (CMS), which requires Medicare Advantage plans to implement chronic-care improvement initiatives.
Real-time identification and workflows raise the pace and likelihood of closing chronic-care gaps.
Targeted gap-closure drives stronger performance in CCM, Star Ratings and value-based contracts.
Early identification and coordinated follow-through reduce disease progression and downstream costs.
Automated workflows free up care managers to focus on high-impact interventions rather than tracking spreadsheets.
In chronic-disease care, unaddressed gaps are the silent accelerator of poor outcomes and regulatory risk. With its integrated EHR foundation and orchestration engine, blueBriX turns gap-identification into action—closing loops, improving quality metrics and delivering the performance that today’s value-based environment demands.