Gaps In Care

##Overview A gap in care is defined as a discrepancy between recommended best practices and the services that are actually provided and documented. More simply gaps give information as to why a patient isn't in the numerator. If a patient is not in the numerator, our prototype attempts to give detailed information as to why that is the case. Currently this only supports positive improvement and only proportion based scoring (not episode of care or continuous variable)

Types of Gaps:

• OR Gaps - A set of gaps for which only one gap needs to be closed in order for the patient to meet standards for quality of care. These types of gaps are represented by multiple GuidanceResponses within a FHIR DetectedIssue

• AND Gaps - A set of gaps for which every gap must be closed in order for the patient to meet standards for quality of care. This type of gap is represented by

Representing Gaps

Gaps are presented as a resource known as a "GuidanceResponse" as part of a Gaps Bundle containing information for each detected issue. It is important to note that for each detected issue multiple guidance responses can potentially exist.

Instructions on generating this resource can be found here

---

An Example of a Guidance Response for a detected issue for EXM130 is shown below.

  "resourceType": "GuidanceResponse",
  "id": "e3505055-e235-401d-9487-e9e250cc16dd",
  "dataRequirement": [
    {
      "type": "Observation",
      "codeFilter": [
        {
          "path": "code",
          "valueSet": "http://example.com/test-vs"
        }
      ],
      "dateFilter": [
        {
          "path": "effectivePeriod",
          "valuePeriod": {
            "start": "2019-01-01",
            "end": "2019-12-31"
          }
        }
      ]
    }
  ],
  "reasonCode": [
    {
      "coding": [
        {
          "system": "CareGapReasonCodeSystem",
          "code": "DateOutOfRange",
          "display": "Date of required data was out of range"
        }
      ]
    }
  ],
  "status": "data-required",
  "moduleUri": "http://hl7.org/fhir/us/cqfmeasures/Measure/EXM130"
}

Value Filter -A value filter determines whether the resource has a value within a certain range. There is no value filter option currently part of the data requirement type (please note that this portion of the code is under active development and is very much a WIP)

---

Near Misses - A “near miss” is defined as a gap where the Retrieve statement for a data element has a value, but a subsequent query filter on that data element made the clause false

---

CQL Example Using EXM 130

The CQL clauses that will cause a patient to fall into the numerator are listed below:

	exists "Colonoscopy Performed"
		or exists "Fecal Occult Blood Test Performed"
		or exists "Flexible Sigmoidoscopy Performed"
		or exists "Fecal Immunochemical Test DNA"
		or exists "CT Colonography Performed"

A patient that doesn't have a colonoscopy within the set time period (2019) but did have one and meets none of the other criteria in defined in the CQL for a patient to fall into the numerator. For example:

"productOrService": {
              "coding": [{ "system": "http://snomed.info/sct", "code": "73761001", "display": "Colonoscopy" }],
              "text": "Colonoscopy"
            },
            "servicedPeriod": { "start": "2009-09-08T11:21:48-04:00", "end": "2009-09-08T11:36:48-04:00" },
            "locationCodeableConcept": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/ex-serviceplace",
                  "code": "21",
                  "display": "Inpatient Hospital"
                }
              ]
            },

when run against this measure would generate this output that contains this snippet within the DetectedIssue resource for one of the tests conditions that was not met:

          "contained": [
            {
              "resourceType": "GuidanceResponse",
              "id": "5bbfcda9-e6d2-4e0d-9eb0-d9a8443bde5c",
              "dataRequirement": [
                {
                  "type": "Procedure",
                  "codeFilter": [
                    {
                      "path": "code",
                      "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1020"
                    }
                  ]
                }
              ],
              "reasonCode": [
                {
                  "coding": [
                    {
                      "system": "CareGapReasonCodeSystem",
                      "code": "Missing",
                      "display": "No Data Element found from Value Set"
                    }
                  ]
                }
              ],
              "status": "data-required",
              "moduleUri": "http://hl7.org/fhir/us/cqfmeasures/Measure/EXM130"
            },

It flags that there is a CareGapReasonCodeSystem and the reason for that gap is that the patient was missing all of the procedures.