Close Care Screening Gaps Using Your EHR Data

Turn your EHR into a real-time screening registry

Oatmeal Health helps FQHCs automatically identify patients due for high-impact screenings and wellness visits, then operationalize outreach so more patients complete screenings with AI, and your organization captures visit revenue and value-based incentives.

Facing FMAP cuts and workforce shortages?

We help FQHCs protect care access, recover revenue, and serve more patients—especially those you wouldn’t otherwise be able to reach.

Screening gaps are not a motivation problem.
They are a data and workflow problem.

FQHC teams are already working hard. The challenge is that eligibility spans messy, incomplete EHR fields, scanned documents, problem lists, external records, and inconsistent histories. That turns “who is due” into a manual hunt.

Meanwhile, quality incentives are increasingly tied to closing care gaps, and the cost of outbound outreach continues to rise.

  • Staff spend time building lists, running reports, and cleaning data

  • Outreach teams call patients without reliable prioritization

  • Scheduling happens in disconnected workflows

  • The same gaps return every year, and performance targets keep moving

How We Help

We create “universes” of screening-eligible patients from your EHR

Oatmeal Health scrubs your EHR to generate a clear, actionable registry of eligible patients due for specific screenings, then supports outreach workflows to help you close those gaps. Think of it as a screening eligibility engine that can power multiple programs, not a single disease tool.

Demographics
Diagnoses & Conditions
Medications & Labs
Clinical Notes
Your EHR
AI
Screening
Eligibility Engine
Lung Cancer
Cervical
Colorectal
Breast
Diabetes
More
Patient Screening Universe
Click for details · Drag to rearrange

How it Works

Prove value and drive outcomes quickly with a flexible integration approach

Data In

We work with your team to securely pull the minimum EHR data needed to determine eligibility and “due” status. This can be done through integration, or through scheduled exports as a starting point.

Eligibility Logic and Universe Creation

We apply screening criteria to build clean patient lists, then segment them into outreach-ready cohorts.

Prioritization

We can rank or segment lists by practical outreach value, for example, overdue status, likelihood of completion, or your program constraints.

Workflow Enablement

We support operational workflows so the universe becomes completed screenings, not a static report.

Continuous Refresh

Care gaps change. The system refreshes on a defined cadence so outreach stays current.

Patient Universes Created by AI
50,000 patients analyzed
Lung Cancer
7,500 eligible 6%
HEDIS Measure 2028
Gap to Close 7,050 patients
Breast Cancer
8,200 eligible 70%
HEDIS Measure Yes
Gap to Close 2,460 patients
Cervical Cancer
7,200 eligible 60%
HEDIS Measure Yes
Gap to Close 2,880 patients
Colorectal
12,000 eligible 65%
HEDIS Measure Yes
Gap to Close 4,200 patients
Diabetes A1c
8,900 eligible 70%
HEDIS Measure Yes
Gap to Close 2,670 patients
Annual Wellness
42,000 eligible 50%
HEDIS Measure Yes
Gap to Close 21,000 patients

Why FQHC Leaders Care

The model is simple. Staff costs down, visits up, incentives up. This approach is designed for the way FQHCs actually get paid and measured.

Operational Wins

Less manual list-building
and chart review
More focused outreach,
fewer wasted dials
A repeatable playbook
for multiple screening programs
$

Financial Wins

More completed
screening-related visits
Better performance on quality
metrics tied to incentive dollars
A clearer ROI story
for leadership, boards, and partners

Pricing

FQHCs need pricing that is predictable and easy to model. We offer a PMPM pricing that scales with your population.

Calculate Your ROI Based On:

1
Population size
2
Expected conversion rates
3
Visit volume
4
Incentive opportunity in contracts

Pricing Scoped Based On:

Number of screening universes
Refresh frequency
Workflow components
(reporting, routing, scheduling)
Integration requirements

Integration and Security

We meet you where you are, and we keep data handling practical

Integration Options

Integration-based workflows
When feasible — full EHR embedding
Export-based workflows
Fast start, then path to deeper integration

Security & Compliance

Standard healthcare data protections
Appropriate agreements executed
HIPAA compliant

What Does Implementation Look Like?

Start fast with a simple CVS file download from your EHR, no integration needed.

Start with 2-4 screening universes that:

1
Your quality team is actively targeting
2
Have straightforward eligibility criteria
3
Have a clear ROI path in your contracts

Outputs

The universes (clean lists and logic)
Workflow plan for outreach and scheduling
Weekly dashboard of progress and conversion
Results summary and scale plan
Setup
1
Week 1-2
Generate Lists
2
Week 2-3
Outreach
3
Week 3-10
Measure
4
Week 10-12
Scale
Post-Phase 1

Beyond the Funding Cliff: Unlock New Non-Grant Revenue for Your FQHC

New Revenue. Zero Risk. Better Care. Don’t let funding cuts stall your mission. We provide the AI technology, staffing, and oversight to launch a high-value research program at your center at no cost. You receive a percentage of the program’s profit to stabilize your budget, while your patients gain access to life-saving medicine.

Why it Works 

  • 0% Risk: We manage the clinical burden; you retain the mission focus.

  • Unrestricted Funds: Use your share of revenue for any center needs, including facility upgrades, higher salaries, and new hires.

  • Health Equity: Ensure the next generation of life-saving therapies doesn’t leave your patients behind.

FQHC Funding Estimator

Calculate non-grant revenue with zero operational burden.

50,000
Standard Access
Standard
Access
Live System
Integration
Advanced
Clinical Sync
Projected Annual Center Funding
$675,000
The "Zero-Burden" Guarantee: Our team manages 100% of patient identification, outreach, and trial navigation. Your clinical staff remains focused on primary care.

Join the Community, Build Trust with Oatmeal Health

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