Improving Care Gap Closure for HEDIS/Stars with Source-Linked Summaries

Background

A senior-focused primary care organization delivers whole-person outpatient care for older adults. Their clinical model emphasizes longer visits, proactive care coordination, and performance in value-based arrangements (including Medicare Advantage, shared-savings programs, and commercial APMs). Many clinics serve medically underserved communities, where patients often arrive with:

• Long, fragmented medical histories
• Records spread across distant hospitals, specialists, and health systems
• High chronic disease burden
• Complex care-gap requirements tied to quality and risk-adjusted reimbursement

Clinicians frequently needed to review large volumes of outside records - hospital discharges, specialist notes, imaging, labs, and procedure reports - during or immediately before visits. Manual review was becoming unsustainable.

The Challenge

For each patient encounter, clinicians needed fast answers to questions like:

• What are the patient’s active chronic conditions?
• What care gaps are present and require closure?
• Which diagnoses are risk-adjusting, and are they appropriately supported?
• Have there been recent hospitalizations, ED visits, imaging, or medication changes?
• What specialist recommendations need follow-up?

Without automation, record retrieval and review led to:

• Delays in scheduling visits while waiting for external records
• Significant clinician time spent searching charts and PDFs
• Reduced time for patient interaction and care planning
• Higher risk of missing documentation required for quality reporting or risk validation

Why source documentation still matters in value-based care

Value-based organizations routinely need auditable source records to support gap closure, risk validation, and quality reporting. Claims and summary feeds often lack necessary detail, so payers request supporting documentation (e.g., progress notes, reports, lab/imaging results) to validate:

• A qualifying care event occurred
• A diagnosis was assessed/managed and appropriately documented
• A quality measure was satisfied with date/result/provider evidence
• Compliance and audit integrity requirements were met

Here are the key drivers:

1. Audit and quality reporting requirements (e.g., HEDIS/Stars)

Payers must validate that a qualifying care event actually occurred. They therefore require original clinical documentation, such as:

• Chart extracts
• Progress notes
• Imaging or lab reports

2. Risk-Adjustment Validation

To reduce risk-adjustment audit exposure and ensure compliant risk coding, payers need documentation showing that each diagnosis was:

• Clinically appropriate
• Addressed or assessed
• Clearly supported in the encounter note

3. Quality Bonus & Shared Savings Depend on Documentation Integrity

To count a gap as closed (A1c, mammography, colonoscopy, BP control, etc.), payers need source evidence showing:

• Date of service
• Result
• Ordering/performing provider
• Original clinical detail

4. Interoperability Data Is Not Enough

Claims, CCDs, and ADT feeds rarely contain the granularity needed to validate compliance. Thus payers request:

• PDF chart pages
• Lab/imaging reports
• Procedure documentation

5. Compliance & Fraud Prevention

Submitting source records protects both provider and payer by creating a defensible audit trail.

6. It Is Contractually Required in Most Value-Based Care Agreements

Failure to submit documentation can result in:

• Rejected HCCs
• Rejected quality gap closures
• Lower Stars/quality scores
• Lost shared savings

The solution: AI-powered retrieval + summarization + source linking

The organization partnered with Abstractive Health to automate the record-review workflow:

1. High-Performance External Record Retrieval

Retrieving records from hospitals, specialists, and prior providers—often across multiple health systems.

2. Automated Summarization for Primary Care

AI-generated clinical summaries organized around the needs of primary care clinicians:

• Diagnoses and chronic conditions
• Medications
• Procedures and surgeries
• Labs and imaging highlights
• Recent clinical events
• Specialist recommendations
• Longitudinal trends

3. Source Record Surfacing for VBC Documentation

Abstractive doesn’t just summarize—it retrieves and surfaces the exact source pages needed for:

• HEDIS and Stars validation
• HCC/risk adjustment proof
• Gap-closure documentation
• Audit support

4. Real-Time Clinical Intelligence During Visits

Through workflow prompts and question-answering tools, clinicians can instantly ask:

• “Has this patient had a recent A1c?”
• “What were the last imaging results?”
• “Is there documentation supporting this diagnosis?”

5. Seamless Workflow Integration

No major training, no new systems Abstractive fits directly into the clinician’s existing workflow.

The Bottom Line

Abstractive Health helped turn fragmented records into actionable, source-linked clinical intelligence, improving clinical readiness and documentation integrity for value-based care.