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
| 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. |
| topic | is an optional parameter for which the cardinality has been updated to allow multiple topics to be specified. (not implemented) | |
| subject | ✓ | can now point to either a patient or a group of patients. Subject is optional when run a Gaps in Care Report for an organization or a practitioner of an organization. (implemented) |
| practitioner | references a practitioner for which the Gaps in Care Report will be created. | |
| organization | references an organization for which the Gaps in Care Report will be created. | |
| status | ✓ | is required, it SHALL be a code from the gaps status value set, which indicates an open-gap or a closed-gap. For the Gaps in Care Report to return both the open and closed gaps, status equals to open-gap and closed-gap both need to be 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. |
| program | is used to specify one or more programs that a provider or an organization participates in. For example, the program may be a risk based, value based, or other performance program such as the Merit-based Incentive Payment System (MIPS) and Hospital Quality Reporting programs of CMS. |
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
{
"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": {
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
}
],
"reference": "#05cd8670-31c2-4afa-8a27-8a950268699d"
}
}
],
"status": "complete",
"type": "individual",
"measure": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003",
"subject": {
"reference": "Patient/numer-EXM130-Patient-1"
},
"date": "2024-03-05T02:29:22+00:00",
"reporter": {
"reference": "organization-group-1"
},
"period": {
"start": "2021-01-01T00:00:00+00:00",
"end": "2023-12-31T23:59:59+00:00"
},
"improvementNotation": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
"code": "increase"
}
]
},
"group": [
{
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-denominator-membership",
"valueString": "1"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-numerator-membership",
"valueString": "1"
}
],
"population": [
{
"id": "178DA8D8-0694-4B88-8FFE-42CE671EEE35",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "initial-population",
"display": "Initial Population"
}
]
},
"count": 1
},
{
"id": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator",
"display": "Denominator"
}
]
},
"count": 1
},
{
"id": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "denominator-exclusion",
"display": "Denominator Exclusion"
}
]
},
"count": 0
},
{
"id": "14B66980-07F4-4872-83AF-C425C379B971",
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/measure-population",
"code": "numerator",
"display": "Numerator"
}
]
},
"count": 1
}
],
"measureScore": {
"value": 1.0
}
}
],
"evaluatedResource": [
{
"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"
},
{
"url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
"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"
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/DetectedIssue/64cd6948-8d84-43c5-afb7-8e1de1ce76bd",
"resource": {
"resourceType": "DetectedIssue",
"id": "64cd6948-8d84-43c5-afb7-8e1de1ce76bd",
"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:e2696505-77cf-4e85-9c5d-d3b740cd8174"
}
],
"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/61fb95cf-2707-40a3-b899-78a7580b54ce"
}
]
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Organization/organization-group-1",
"resource": {
"resourceType": "Organization",
"id": "organization-group-1",
"meta": {
"versionId": "1",
"lastUpdated": "2024-03-04T15:38:56.843+00:00",
"source": "#LN6pEhFDHzMRJTrl"
},
"identifier": [
{
"use": "official",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "TAX",
"display": "Tax ID Number"
}
]
},
"value": "000014522"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "pay"
}
],
"text": "Payer"
}
],
"name": "Group Organization",
"telecom": [
{
"system": "phone",
"value": "(+1) 555-555-5555"
},
{
"system": "email",
"value": "hq@acme.org"
}
],
"address": [
{
"line": [
"100 Insurance Avenue"
],
"city": "Amherst",
"state": "MA",
"postalCode": "01002",
"country": "USA"
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Organization/organization-group-1",
"resource": {
"resourceType": "Organization",
"id": "organization-group-1",
"meta": {
"versionId": "1",
"lastUpdated": "2024-03-04T15:38:56.843+00:00",
"source": "#LN6pEhFDHzMRJTrl"
},
"identifier": [
{
"use": "official",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "TAX",
"display": "Tax ID Number"
}
]
},
"value": "000014522"
}
],
"active": true,
"type": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/organization-type",
"code": "pay"
}
],
"text": "Payer"
}
],
"name": "Group Organization",
"telecom": [
{
"system": "phone",
"value": "(+1) 555-555-5555"
},
{
"system": "email",
"value": "hq@acme.org"
}
],
"address": [
{
"line": [
"100 Insurance Avenue"
],
"city": "Amherst",
"state": "MA",
"postalCode": "01002",
"country": "USA"
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Patient/numer-EXM130-Patient-1",
"resource": {
"resourceType": "Patient",
"id": "numer-EXM130-Patient-1",
"meta": {
"versionId": "1",
"lastUpdated": "2024-03-04T15:39:05.393+00:00",
"source": "#jHv5rnS3TIf8vzxr",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"
]
},
"extension": [
{
"url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race",
"extension": [
{
"url": "ombCategory",
"valueCoding": {
"system": "urn:oid:2.16.840.1.113883.6.238",
"code": "2028-9",
"display": "Asian"
}
}
]
},
{
"url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity",
"extension": [
{
"url": "ombCategory",
"valueCoding": {
"system": "urn:oid:2.16.840.1.113883.6.238",
"code": "2135-2",
"display": "Hispanic or Latino"
}
}
]
}
],
"identifier": [
{
"use": "usual",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "MR",
"display": "Medical Record Number"
}
]
},
"system": "http://hospital.smarthealthit.org",
"value": "999999992"
}
],
"name": [
{
"family": "Blitz",
"given": [
"Don"
]
}
],
"gender": "male",
"birthDate": "1965-01-01",
"generalPractitioner": [
{
"reference": "Practitioner/practitioner-group-org-1"
}
]
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Encounter/numer-EXM130-Encounter-1",
"resource": {
"resourceType": "Encounter",
"id": "numer-EXM130-Encounter-1",
"meta": {
"versionId": "1",
"lastUpdated": "2024-03-04T15:39:05.393+00:00",
"source": "#jHv5rnS3TIf8vzxr",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter"
]
},
"status": "finished",
"class": {
"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
"code": "AMB",
"display": "ambulatory"
},
"type": [
{
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "99201",
"display": "Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family."
}
]
}
],
"subject": {
"reference": "Patient/numer-EXM130-Patient-1"
},
"period": {
"start": "2023-05-30T00:00:00.0",
"end": "2023-05-31T00:00:00.0"
}
}
},
{
"fullUrl": "https://cdr-qa-cluster.alphora.com/fhir_request/Procedure/numer-EXM130-1",
"resource": {
"resourceType": "Procedure",
"id": "numer-EXM130-1",
"meta": {
"versionId": "1",
"lastUpdated": "2024-03-04T15:39:05.393+00:00",
"source": "#jHv5rnS3TIf8vzxr",
"profile": [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure"
]
},
"status": "completed",
"code": {
"coding": [
{
"system": "http://www.ama-assn.org/go/cpt",
"code": "44388",
"display": "Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique"
}
]
},
"subject": {
"reference": "Patient/numer-EXM130-Patient-1"
},
"performedPeriod": {
"start": "2014-01-01T00:00:00-06:00",
"end": "2014-01-01T01:00:00-07:00"
}
}
}
]
}
}
]
}
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