11.2.1Care Gaps A gap in care refers to a discrepancy or gap in a patient's care that has been identified through analysis of their medical records, history, and current health status.

These gaps can include missing or incomplete information, unmet health needs, and opportunities for preventative care or intervention. Identifying and addressing care gaps can help improve the quality of care provided to patients, reduce healthcare costs, and ultimately lead to better health outcomes.

Example: This woman was supposed to have a breast cancer screening this year but did not. Let’s reach out to her and get that scheduled.

A Gaps in Care Report is designed to communicate actual or perceived gaps in care between systems, such as the payer’s system and provider’s EMR. The report provides opportunities for providers to provide missing care and/or to communicate care provision data to payers. The report may also provide information for upcoming care opportunities, prospective gaps.

The gaps in care flow is between a provider and a measurement organization’s system performing analytics.

Care Gaps FlowSourced from Implementation Guide

The Gaps in Care Reporting uses the DEQM Individual MeasureReport Profile. This allows the Gaps in Care Reporting to use the same machinery as the Individual Reporting to calculate measures and represent the results of individual calculation.

The following resources are used in the Gaps in Care Reporting Scenario:

Report TypeProfile NameLink to Profile
BundleDEQM Gaps In Care Bundle ProfileDEQM Gaps In Care Bundle Profile
CompositionDEQM Gaps In Care Composition ProfileDEQM Gaps In Care Composition Profile
DetectedIssueDEQM Gaps In Care DetectedIssue ProfileDEQM Gaps In Care Detected Profile
GroupDEQM Gaps In Care Group ProfileDEQM Gaps In Care Group Profile
MeasureReportDEQM Gaps In Care MeasureReport ProfileDEQM Gaps In Care MeasureReport Profile in Care Reporting [Gaps through period](http://hl7.org/fhir/us/davinci-deqm/2023Jan/index.html#glossary) is the time period defined by a Client for running the Gaps in Care Report.

  • When the gaps through period ends on a date that is in the future, the Gaps in Care Reporting is said to look for care gaps prospectively. In this scenario, it provides providers with opportunities to assess anticipated open gaps and take proper actions to close the gaps.
  • When the gaps through period ends on a date that is in the past, the Gaps in Care Reporting is said to look for care gaps retrospectively. In the retrospective scenario, identified open gaps can no longer be acted upon to meet the quality measure.
Use Casecare-gaps OperationGaps Through Period Start DateGaps Through Period End DateReport Calculated DateColorectal Cancer Screening - Colonoscopy DateGaps in Care Report
Prospective Use Case$care-gaps?periodStart=2021-01-01&periodEnd=2021-06-30&subject=Patient/123&measureId=EXM130-7.3.000&status=open-gap2021-01-012021-06-302021-04-01Example: patient had colonoscopy on 2011-05-03Returns gaps through 2021-06-30. The Gaps in Care Report indicates the patient has an open gaps for the colorectal cancer screening measure. By 2021-06-30, the colonoscopy would be over 10 years.
Retrospective Use Case$care-gaps?periodStart=2020-01-01&periodEnd=2020-12-31&subject=Patient/123&measureId=EXM130-7.3.000&status=open-gap2020-01-012020-12-312021-04-01Example: patient had colonoscopy on 2011-05-03Returns gaps through 2020-12-31. The Gaps in Care Report indicates the patient has a closed gaps for the colorectal cancer screening measure. Since on 2020-12-31, the procedure would have occurred within the specified 10-year timeframe. Hapi FHIR implements the [$care-gaps](http://hl7.org/fhir/us/davinci-deqm/2023Jan/OperationDefinition-care-gaps.html) operation. Gaps The `$care-gaps` operation is used to run a Gaps in Care Report. care gaps on Hapi FHIR Hapi FHIR is integrated with `$care-gaps` operations and following are the steps to identify open gap on sample data following the remediation step to generate a report for closed gap.

All the sample files used below are available on hapi-fhir code base under resources folder.

  1. Submit payer content
POST http://localhost/fhir/ CaregapsColorectalCancerScreeningsFHIR-bundle.json
  1. Submit payer org data
POST http://localhost/fhir/ CaregapsAuthorAndReporter.json
  1. Submit provider data
POST http://localhost/fhir/Measure/ColorectalCancerScreeningsFHIR/$submit-data CaregapsPatientData.json
  1. Provider runs care-gaps operation to identify open gap.
GET http://localhost/fhir/Measure/$care-gaps?periodStart=2020-01-01&periodEnd=2020-12-31&status=open-gap&status=closed-gap&subject=Patient/end-to-end-EXM130&measureId=ColorectalCancerScreeningsFHIR
  1. Provider fixes gaps
POST http://localhost/fhir/Measure/ColorectalCancerScreeningsFHIR/$submit-data CaregapsSubmitDataCloseGap.json
  1. Provider runs care-gaps operation to identify the gap is closed.
GET http://localhost/fhir/Measure/$care-gaps?periodStart=2020-01-01&periodEnd=2020-12-31&status=open-gap&status=closed-gap&subject=Patient/end-to-end-EXM130&measureId=ColorectalCancerScreeningsFHIR