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.
Sourced 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 Type||Profile Name||Link to Profile|
|Bundle||DEQM Gaps In Care Bundle Profile||DEQM Gaps In Care Bundle Profile|
|Composition||DEQM Gaps In Care Composition Profile||DEQM Gaps In Care Composition Profile|
|DetectedIssue||DEQM Gaps In Care DetectedIssue Profile||DEQM Gaps In Care Detected Profile|
|Group||DEQM Gaps In Care Group Profile||DEQM Gaps In Care Group Profile|
|MeasureReport||DEQM Gaps In Care MeasureReport Profile||DEQM Gaps In Care MeasureReport Profile|
|Use Case||care-gaps Operation||Gaps Through Period Start Date||Gaps Through Period End Date||Report Calculated Date||Colorectal Cancer Screening - Colonoscopy Date||Gaps in Care Report|
|Prospective Use Case||$care-gaps?periodStart=2021-01-01&periodEnd=2021-06-30&subject=Patient/123&measureId=EXM130-7.3.000&status=open-gap||2021-01-01||2021-06-30||2021-04-01||Example: patient had colonoscopy on 2011-05-03||Returns gaps through 2021-06-30. The Gaps in Care Report indicates the patient has an open gaps for the colorectal cancer screening measure. By 2021-06-30, the colonoscopy would be over 10 years.|
|Retrospective Use Case||$care-gaps?periodStart=2020-01-01&periodEnd=2020-12-31&subject=Patient/123&measureId=EXM130-7.3.000&status=open-gap||2020-01-01||2020-12-31||2021-04-01||Example: patient had colonoscopy on 2011-05-03||Returns 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.|
All the sample files used below are available on hapi-fhir code base under resources folder.
POST http://localhost/fhir/ CaregapsColorectalCancerScreeningsFHIR-bundle.json
POST http://localhost/fhir/ CaregapsAuthorAndReporter.json
POST http://localhost/fhir/Measure/ColorectalCancerScreeningsFHIR/$submit-data CaregapsPatientData.json
POST http://localhost/fhir/Measure/ColorectalCancerScreeningsFHIR/$submit-data CaregapsSubmitDataCloseGap.json