The identification of care gaps, instances where a patient is not receiving evidence-based or recommended care, can unlock substantial economic value for both health insurance payors and providers. HEDIS and CMS (Centers for Medicare and Medicaid Services) STAR ratings rely on care gap closure and these directly impact bonus payments and plan ratings. Every 0.5 STAR increase can mean ~$50–100 per member per year in quality bonuses, and accurate coding via gap identification can result in thousands of dollars per high-risk patient in adjusted revenue.
Providers and payors are increasingly turning to technology to proactively identify and close care gaps—missed screenings, overdue follow-ups, and unmanaged chronic conditions. By combining human-centered design (HCD) and the use of modern data platforms, cloud infrastructure, and AI-powered analytics, providers and payors can improve outcomes, reduce costs, and enhance member satisfaction while ensuring that these solutions are not only efficient but also empathetic, accessible, and aligned with real-world needs. Below are four ways HCD enhances the automation of care gap identification and four ways to optimize the automation of care gap identification with technology.
How Human-Centered Design Supports the Automation of Care Gap Identification
At its core, Human-Centered Design (HCD) is about designing solutions that are not only functional but also empathetic, accessible, and aligned with real-world human needs. HCD emphasizes understanding the people you’re designing for through direct engagement, observation, and iteration.
1. Grounding Automation in Human Needs
Effective automation begins with a deep understanding of the people it serves. Human-centered design emphasizes ethnographic research, usability testing, and stakeholder interviews to uncover the real challenges faced by patients, providers, and care managers. This ensures that automated systems target the most meaningful care gaps and reflect how individuals actually navigate healthcare services.
2. Designing for Trust and Engagement
Automation is only effective if users trust and engage with it. HCD helps create intuitive, accessible interfaces that resonate with diverse populations. By using clear language, culturally relevant visuals, and transparent communication, providers and payors can build trust and encourage patients and members to act on automated prompts—whether it’s scheduling a screening or following up on a care plan.
3. Mapping the Service Ecosystem
Human-centered design tools like journey mapping and service blueprinting help visualize the full care delivery and administrative landscape. This allows providers and payors to identify upstream and downstream barriers to care, prioritize automation opportunities, and align member-facing and operational workflows for maximum impact.
4. Aligning with Strategic Innovation
HCD ensures that automation initiatives support broader organizational goals such as cost reduction, regulatory compliance, and improved member satisfaction. It fosters cross-functional collaboration, clarifies problem statements, and surfaces overlooked opportunities for innovation—making automation not just a technical upgrade, but a strategic advantage.
Automating Care Gap Identification: A Technology-Driven Approach for Health Insurance Payors
1. Unified Data Platforms and Lakehouse Architectures
Modern cloud analytics platforms offer a unified foundation for ingesting, harmonizing, and analyzing multi-modal data from electronic health records (EHRs), claims systems, and social determinants of health. A medallion-style lakehouse architecture structures this data into three layers:
- Bronze (Raw Zone): Stores unprocessed data from patient encounters and treatment adherence.
- Silver (Enriched Zone): Transforms raw data into standardized formats using healthcare interoperability standards.
- Gold (Curated Zone): Refines data for advanced analytics, enabling predictive modeling and care gap identification.
This architecture supports real-time monitoring and predictive analytics, allowing providers and payors to proactively surface care opportunities.
2. Automated Quality Reporting and Monitoring
Technology platforms can streamline quality reporting frameworks such as HEDIS by:
- Aggregating data from EHRs, claims, and patient surveys.
- Performing automated validation and quality checks.
- Enabling real-time performance monitoring and benchmarking.
- Incorporating predictive analytics to flag potential care gaps before they impact compliance.
These capabilities help providers and payors maintain high quality scores and meet regulatory requirements efficiently.
3. Scalable Cloud Infrastructure and EHR Integration
Hosting EHR systems and analytics platforms on scalable cloud infrastructure enhances performance, security, and flexibility. These environments support seamless integration with AI tools that automate care gap detection and streamline workflows for care managers and providers.
4. Responsible AI and Data Governance
Responsible use of AI is critical in healthcare. Modern data platforms include tools for:
- De-identifying sensitive health data.
- Managing data access, lineage, and compliance.
- Ensuring ethical and transparent use of AI in healthcare analytics.
Bringing HCD & Automation Together: How Vervint Helps
The automation of care gap identification through Human-Centered Design (HCD) and advanced technology platforms offers a transformative approach to improving healthcare outcomes. By leveraging modern data platforms, cloud infrastructure, and AI-powered analytics, providers and payors can proactively identify and close care gaps, ensuring that patients receive timely and evidence-based care. Vervint can help by providing cutting-edge solutions that integrate HCD principles with robust technological frameworks, enabling healthcare organizations to enhance member satisfaction, reduce costs, and achieve higher quality scores. With Vervint’s expertise, healthcare providers and payors can navigate the complexities of care gap closure and drive meaningful improvements in patient care and operational efficiency.
Our work with one client, a medical device company, addressed the challenge of optimizing patient flow and enhancing staff and patient experiences. The client challenge focused on improving patient flow and enhancing the adoption and use of technology. Key outcomes of our work included HCD research on existing user interface/user experience concepts, solidifying the dashboard reporting personalization experience, and exploring how to display device-specific data, such as location. Our approach involved building and maintaining a research panel, conducting usability testing, and facilitating design thinking workshops to facilitate the definition and implementation of the best technology solution. The project built trust with stakeholders, implemented a continuous improvement process, and delivered a data-driven, automated solution, realizing value in both time and experience, through the combination of Human-Centered Design and innovative technology.
