Automated Suggestions and Monitoring in a Longitudinal Care Plan

A computerized method comprising:

• monitoring a gap in care for a patient;
• automatically determining the patient has completed at least one measure addressing a gap in care corresponding to a particular condition in a longitudinal care plan of the patient;
• and
• based on the completed at least one measure, automatically updating the longitudinal care plan of the patient.

A system comprising:

• a processor;
• and
• a computer storage medium storing computer-usable instructions that, when used by the processor, cause the processor to:
• access a registry corresponding to a particular condition of a patient;
• automatically determine the patient has a gap in care corresponding to the particular condition in a longitudinal care plan of a patient;
• automatically create at least one measure on the longitudinal care plan of the patient to address the gap in care;
• monitor a status of the at least one measure for the patient;
• determine the patient has completed the at least one measure that addresses the gap in care;
• and
• based on the completed at least one activity, automatically update the longitudinal care plan of the patient.