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.
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 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.
A Measure Bundle that can run an evaluate-measure operation is required before $care-gaps operation can be run. See Measure Evaluations for more information on evaluating quality measures.
In order to use this operation, you need to start the DQM Module
example bundle for Colorectal Cancer Screenings
| Scoring Method | Supported | Description |
|---|---|---|
| proportion | ✓ | Proportion Measures |
| ratio | ✓ | Ratio Measures |
| continuous-variable | Continuous Variable | |
| cohort | Cohort | |
| composite |
| Measure Basis | Supported | Description |
|---|---|---|
| resource | Measures that have population counts that are qty of Resources that match criteria of expression. Example: qty of Encounter resources. | |
| boolean | ✓ | Measures that have population count that are of value true (boolean) for criteria of expression. Example: does patient have qualifying Encounter |
$care-gaps could produce one 'Detected Issue' resource per group.As of 2024.11.R01, 'prospective-gap' status can evaluate for Measures that are set up to calculate "Date of Compliance" returned value within a MeasureReport.group.extension.
This conformant Measure resource would then be able to return an extension with the calculated DateTime Interval.
If no extension to calculate "Date of Compliance" is provided on the Measure.group, or no DateTime Interval is returned by the expression, then 'prospective-gap' can't be calculated.
The "Date of Compliance" Interval, Measure Report date, along with the Measure Report population results would determine if it is a 'prospective-gap'.
GET http://localhost/fhir_request/Measure/$care-gaps?measureId=ColorectalCancerScreeningsFHIR&subject=Patient/numer-EXM130-Patient-1&status=prospective-gap&periodStart=2021-01-01&periodEnd=2023-12-31
Where the specified cql expression referenced would require a return of type Interval[DateTime,DateTime].
{
"extension": [ {
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "date of compliance"
}
} ]
}
{
"id": "MinimalProportionResourceBasisSingleGroupWithDOC",
"resourceType": "Measure",
"url": "http://example.com/Measure/MinimalProportionResourceBasisSingleGroupWithDOC",
"library": [
"http://example.com/Library/MinimalProportionResourceBasisSingleGroup"
],
"extension": [ {
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
"valueCode": "encounter"
}
],
"scoring": {
"coding": [
{
"system": "http://hl7.org/fhir/measure-scoring",
"code": "proportion"
}
]
},
"group": [
{
"extension": [ {
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valueExpression": {
"language": "text/cql-identifier",
"expression": "date of compliance"
}
} ],
"population": [
{
"id": "initial-population",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Initial Population"
}
},
{
"id": "denominator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Denominator"
}
},
{
"id": "denominator-exclusion",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator-exclusion",
"display": "Denominator-Exclusion"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Denominator Exclusion"
}
},
{
"id": "denominator-exception",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator-exception",
"display": "Denominator-Exception"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Denominator Exception"
}
},
{
"id": "numerator-exclusion",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator-exclusion",
"display": "Numerator-Exclusion"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Numerator Exclusion"
}
},
{
"id": "numerator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"criteria": {
"language": "text/cql-identifier",
"expression": "Numerator"
}
}
]
}
]
}
| Parameter | Supported | Description |
|---|---|---|
| periodStart | ✓ | is still required, but the description is modified to reference the start date of the gaps through period. |
| periodEnd | ✓ | is still required, but the description is modified to reference the end of the gaps through period. |
| subject | ✓ | can now point to either a patient, practitioner, or a group of patients. If empty value is passed in, all patients in system will be used. |
| status | ✓ | is required, it SHALL be a code from the gaps status value set, which indicates an 'open-gap', 'closed-gap', 'prospective-gap', and 'not-applicable'. For the Gaps in Care Report to return DetectedIssue results that match the passed in 'status' provided. |
| measureId | ✓ | is the id of a Measure resource that is on the server for which the gaps in care will be reported. The Client will need to check with the Server to know the identifiers used by the Server to uniquely identify measures. This parameter is one of the three options provided by this operation to specify one or more measures for which the Gaps in Care Report will be created. |
| measureIdentifier | ✓ | is the business identifier for a measure. This parameter is one of the three options provided by this operation to specify one or more measures for the which the Gaps in Care Report will be created. |
| measureUrl | ✓ | is the url of a measure. This parameter is one of the three options provided by this operation to specify one or more measures for the which the Gaps in Care Report will be created. |
| nonDocument | ✓ | defaults to 'false', if left empty, which returns standard 'document' bundle. If 'true', this will return summarized subject bundle with only detectedIssue & contained MeasureReport as evidence. |
Also note that measurement period is subject to influence of timezone header value passed into FHIR request header, see headers with fhir requests.
GET http://localhost/fhir_request/Measure/$care-gaps?measureId=ColorectalCancerScreeningsFHIR&subject=Patient/numer-EXM130-Patient-1&status=open-gap&status=closed-gap&periodStart=2021-01-01&periodEnd=2023-12-31
GET http://localhost/fhir_request/Measure/$care-gaps?measureId=ColorectalCancerScreeningsFHIR&subject=Patient/numer-EXM130-Patient-1&status=open-gap&status=closed-gap&periodStart=2021-01-01&periodEnd=2023-12-31&nonDocument=true
How $care-gaps status algorithm interprets a 'Measure Report' that results in prospective-gap status.
{
"resourceType": "MeasureReport",
"id": "a43392e2-9844-45dd-8df8-72d82d2d848e",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/indv-measurereport-deqm"
]
},
"status": "complete",
"type": "individual",
"measure": "http://example.com/Measure/MinimalProportionBooleanBasisSingleGroupWithDOC",
"subject": {
"reference": "Patient/male-2022"
},
"date": "2024-06-15T09:59:08-06:00",
"period": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
},
"group": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valuePeriod": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
}
}
],
"population": [
{
"id": "initial-population",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"count": 1
},
{
"id": "denominator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"count": 1
},
{
"id": "numerator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"count": 0
}
],
"measureScore": {
"value": 0.0
}
}
]
}
Explanation: Results of Denominator=1 and not Numerator=0 on a Measure Report. The patient is in an open-gap status, meaning they meet the criteria for the measure, but have not received appropriate care.
The Report Date is within or before the Date of Compliance interval, therefore there is opportunity to provide care within recommended window of time.
Result: prospective-gap.
How $care-gaps status algorithm interprets a 'Measure Report' that results in open-gap status.
{
"resourceType": "MeasureReport",
"id": "a43392e2-9844-45dd-8df8-72d82d2d848e",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/indv-measurereport-deqm"
]
},
"status": "complete",
"type": "individual",
"measure": "http://example.com/Measure/MinimalProportionBooleanBasisSingleGroupWithDOC",
"subject": {
"reference": "Patient/male-2022"
},
"date": "2025-06-15T09:59:08-06:00",
"period": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
},
"group": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valuePeriod": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
}
}
],
"population": [
{
"id": "initial-population",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"count": 1
},
{
"id": "denominator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"count": 1
},
{
"id": "numerator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"count": 0
}
],
"measureScore": {
"value": 0.0
}
}
]
}
Explanation: Results of Denominator=1 and not Numerator=0 on a Measure Report. The patient is in an open-gap status, meaning they meet the criteria for the measure, but have not received appropriate care.
The Report Date is after the Date of Compliance interval, therefore there is no opportunity to provide care within recommended window of time.
Result: open-gap.
How $care-gaps status algorithm interprets a 'Measure Report' that results in closed-gap status.
{
"resourceType": "MeasureReport",
"id": "a43392e2-9844-45dd-8df8-72d82d2d848e",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/indv-measurereport-deqm"
]
},
"status": "complete",
"type": "individual",
"measure": "http://example.com/Measure/MinimalProportionBooleanBasisSingleGroupWithDOC",
"subject": {
"reference": "Patient/male-2022"
},
"date": "2025-06-15T09:59:08-06:00",
"period": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
},
"group": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valuePeriod": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
}
}
],
"population": [
{
"id": "initial-population",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"count": 1
},
{
"id": "denominator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"count": 1
},
{
"id": "numerator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"count": 1
}
],
"measureScore": {
"value": 1.0
}
}
]
}
Explanation: Results of Denominator=1 and not Numerator=1 on a Measure Report. The patient is in an closed-gap status, meaning they meet the criteria for the measure, and have received appropriate care.
Result: closed-gap.
How $care-gaps status algorithm interprets a 'Measure Report' that results in not-applicable status.
{
"resourceType": "MeasureReport",
"id": "a43392e2-9844-45dd-8df8-72d82d2d848e",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/indv-measurereport-deqm"
]
},
"status": "complete",
"type": "individual",
"measure": "http://example.com/Measure/MinimalProportionBooleanBasisSingleGroupWithDOC",
"subject": {
"reference": "Patient/male-2022"
},
"date": "2024-06-15T09:59:08-06:00",
"period": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
},
"group": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-care-gap-date-of-compliance-expression",
"valuePeriod": {
"start": "2024-01-01T00:00:00-07:00",
"end": "2024-12-31T00:00:00-07:00"
}
}
],
"population": [
{
"id": "initial-population",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"count": 1
},
{
"id": "denominator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"count": 0
},
{
"id": "numerator",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"count": 0
}
],
"measureScore": {
"value": 0.0
}
}
]
}
Explanation: Results of Denominator=0 on a Measure Report. The patient is in an not-applicable status, meaning they do not meet the criteria for the measure, and are not relevant for recommended care.
Result: not-applicable.
{
"resourceType": "DetectedIssue",
"id": "19b18c06-ce51-4afa-a7d7-c8b65d522851",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/gaps-detectedissue-deqm"
]
},
"modifierExtension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-gapStatus",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/us/davinci-deqm/CodeSystem/gaps-status",
"code": "closed-gap",
"display": "Closed Gap"
}
]
}
}
],
"identifier": [
{
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:0a71da45-8fd2-4548-ada7-df0cf9691d63"
}
],
"status": "final",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "CAREGAP",
"display": "Care Gaps"
}
]
},
"patient": {
"reference": "Patient/numer-EXM130-Patient-1"
},
"evidence": [
{
"detail": [
{
"reference": "MeasureReport/146e4d91-607a-40d8-b3a3-70f3f5ed3f24"
}
]
}
]
}
{
"resourceType": "Parameters",
"id": "care-gaps-report-d2e03d9a-43c8-445d-a3af-d0d1ecfcdb2c",
"parameter": [
{
"id": "subject-numer-EXM130-Patient-1",
"name": "return",
"resource": {
"resourceType": "Bundle",
"id": "f21c0731-9de5-4390-ad5d-4257bcba237f",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/gaps-bundle-deqm"
]
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:5419b676-bc8b-4af7-b976-25196d564151"
},
"type": "document",
"timestamp": "2024-03-05T02:29:22.931+00:00",
"entry": [
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Composition/5507c6a0-a3e3-415f-a0ed-bf77c70fbea3",
"resource": {
"resourceType": "Composition",
"id": "5507c6a0-a3e3-415f-a0ed-bf77c70fbea3",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/gaps-composition-deqm"
]
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:1bee456d-1ac5-42d9-a2e8-62312edd8aaa"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "96315-7",
"display": "Gaps in care report"
}
]
},
"subject": {
"reference": "Patient/numer-EXM130-Patient-1"
},
"date": "2024-03-05T02:29:21+00:00",
"author": [
{
"reference": "Organization/organization-group-1"
}
],
"title": "Care Gap Report for numer-EXM130-Patient-1",
"section": [
{
"id": "09ff0272-0c6b-4f0e-8d8a-c6d098d0b5a2",
"title": "Colorectal Cancer ScreeningFHIR",
"focus": {
"reference": "MeasureReport/61fb95cf-2707-40a3-b899-78a7580b54ce"
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>No detected issues.</p></div>"
},
"entry": [
{
"reference": "DetectedIssue/64cd6948-8d84-43c5-afb7-8e1de1ce76bd"
}
]
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/MeasureReport/61fb95cf-2707-40a3-b899-78a7580b54ce",
"resource": {
"resourceType": "MeasureReport",
"id": "61fb95cf-2707-40a3-b899-78a7580b54ce",
"meta": {
"profile": [
"http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/indv-measurereport-deqm"
]
},
"language": "en",
"contained": [
{
"resourceType": "Observation",
"id": "05cd8670-31c2-4afa-8a27-8a950268699d",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
"extension": [
{
"url": "measure",
"valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
}
]
}
],
"status": "final",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code": "supplemental-data"
}
]
},
"valueCodeableConcept": {
"coding": [
{
"code": "2028-9"
}
]
}
},
{
"resourceType": "Observation",
"id": "2e263cbd-efc5-4b26-a47d-0bfa7ed2f09c",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
"extension": [
{
"url": "measure",
"valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
}
]
}
],
"status": "final",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code": "supplemental-data"
}
]
},
"valueCodeableConcept": {
"coding": [
{
"code": "M"
}
]
}
},
{
"resourceType": "Observation",
"id": "a8cbc695-6b13-4aec-9db7-e4ddb7e6f229",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
"extension": [
{
"url": "measure",
"valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
}
]
}
],
"status": "final",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code": "supplemental-data"
}
]
},
"valueCodeableConcept": {
"coding": [
{
"code": "2135-2"
}
]
}
}
],
"extension": [
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.population.description",
"valueString": "Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer"
},
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
"valueReference": {
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
}
],
"reference": "#2e263cbd-efc5-4b26-a47d-0bfa7ed2f09c"
}
},
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
"valueReference": {
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
}
],
"reference": "#a8cbc695-6b13-4aec-9db7-e4ddb7e6f229"
}
},
{
"url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
"valueReference": {
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"valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
}
],
"reference": "Patient/numer-EXM130-Patient-1"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "178DA8D8-0694-4B88-8FFE-42CE671EEE35"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C"
}
],
"reference": "Encounter/numer-EXM130-Encounter-1"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "14B66980-07F4-4872-83AF-C425C379B971"
}
],
"reference": "Procedure/numer-EXM130-1"
}
]
}
]
}
}
]
}
}
]
}
care-gaps operation in order to start the dQM module.See here for Dqm Module Configuration Categories
See here for Dqm Module Configuration Categories
See here for Dqm Module Configuration Categories