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Overview

Care Gaps automatically identifies missing or incomplete care for patients based on HEDIS quality measures. The system analyzes patient data to determine whether recommended screenings, preventive care, and treatments have been completed according to evidence-based guidelines. Care gaps are represented as MeasureReport resources that capture the results of quality measure calculations, including population membership (initial population, denominator, numerator) and supporting evidence used in the calculation. Care Gaps runs at scheduled intervals and analyzes your patient population to identify opportunities for improving care quality and closing gaps in care delivery.

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Available Measures

The following HEDIS measures are currently supported:
MeasureCode
Breast Cancer ScreeningBCSE
Colorectal Cancer ScreeningCOLE

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Getting Started

Care Gaps runs at scheduled intervals and analyzes your patient data to identify gaps in care. Once care gaps is enabled for your account, results will be available through the API and data warehouse.

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Accessing via API

You can retrieve care gap records using the GET /medical/v1/care-gap endpoint. Care gaps are returned as FHIR MeasureReport resources with embedded supporting evidence.

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Accessing via Data Warehouse

Care gap records are stored as MeasureReport resources in the data warehouse.

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Table Schemas

For detailed schema information about the MEASURE_REPORT table, see the MeasureReport schema documentation.

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Identifying Care Gaps

A care gap exists when a patient:
  1. Is in the initial population (count = 1)
  2. Is in the denominator (count = 1)
  3. Is NOT in the denominator exclusion (count = 0)
  4. Is NOT in the numerator (count = 0)

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The Care Gap Model

When a care gap is identified, the API returns a FHIR MeasureReport resource with the following structure: 
{
  "resourceType": "MeasureReport",
  "id": "00000000-0000-0000-0000-000000000000",
  "meta": {
    "extension": [
      {
        "url": "http://metriport.com/fhir/StructureDefinition/supporting-evidence",
        "valueReference": {
          "reference": "#11111111-1111-1111-1111-111111111111"
        }
      }
    ]
  },
  "contained": [
    {
      "resourceType": "Parameters",
      "id": "11111111-1111-1111-1111-111111111111",
      "parameter": [
        {
          "name": "Age at end of measurement period",
          "valueInteger": 42
        },
        {
          "name": "Initial population",
          "valueBoolean": true
        },
        {
          "name": "Denominator",
          "valueBoolean": true
        },
        {
          "name": "Numerator",
          "valueBoolean": false
        },
        {
          "name": "Mammography screening period",
          "valuePeriod": {
            "start": "2023-10-01",
            "end": "2025-12-31"
          }
        }
      ]
    }
  ],
  "status": "complete",
  "type": "individual",
  "measure": "http://ncqa.org/fhir/Measure/BCSE-Details",
  "subject": {
    "reference": "Patient/22222222-2222-2222-2222-222222222222"
  },
  "date": "2025-12-05T14:30:15Z",
  "period": {
    "start": "2025-01-01",
    "end": "2025-12-31"
  },
  "group": [
    {
      "id": "BreastCancerScreening",
      "code": {
        "coding": [
          {
            "system": "https://ncqa.org/fhir/CodeSystem/measure-group",
            "code": "BreastCancerScreening"
          }
        ]
      },
      "population": [
        {
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/CodeSystem/measure-population",
                "code": "initial-population"
              }
            ]
          },
          "count": 1
        },
        {
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/CodeSystem/measure-population",
                "code": "denominator-exclusion"
              }
            ]
          },
          "count": 0
        },
        {
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/CodeSystem/measure-population",
                "code": "denominator"
              }
            ]
          },
          "count": 1
        },
        {
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/CodeSystem/measure-population",
                "code": "numerator"
              }
            ]
          },
          "count": 0
        }
      ]
    }
  ]
}

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Additional Information

For more information about working with patient data, see the data analytics documentation.