Quality Gap Closure

Quality Gap Closure is about finding patients who are due for a screening, test or follow-up, and getting them the care before the measurement year ends. Claims alone arrive late and miss care delivered elsewhere. Zus adds outside labs, pharmacy fills, visits and screenings to each patient's record, so quality teams can see what's actually been done and spend outreach on the patients who still need it.

Care teams see this in the ZAP, where a screening or test done at another organization shows up in the patient's record. Analysts work across the whole population in the data marts. The examples below show three ways teams use Zus data to close gaps.

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Learn more in the clinical guide

For how care teams use the ZAP for quality work, see Quality Gap Closure in the clinical guide.

Before you start

• Patients enrolled in a subscription, so lab and pharmacy data keep flowing in. Lab Networks adds 2 years of Quest Diagnostics history plus new results as they arrive.
• Access to the FHIR Relational Data Marts. See Data Mart Access Options.
• The sample queries in Identifying care gaps. Each one links to SQL you can run and adapt.

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Record requests must be for treatment

Requests to CommonWell, Carequality and Surescripts must be for treating a patient. You can't query the networks only to collect evidence for quality reporting, such as eCQM or HEDIS. See Risk Adjustment for the full rule.

Check outside records before colorectal screening outreach

Goal: stop reaching out to patients who were already screened somewhere else.

1. Run the missing colorectal cancer screenings query. It pulls screening tests (such as FOBT, sDNA FIT and CT colonography) and procedures (such as colonoscopy and flexible sigmoidoscopy) from every source in the record.
2. The query excludes patients with a prior colorectal cancer diagnosis or a colectomy, and keeps patients aged 45 to 75.
3. Compare the results with your own gap list. Patients with an outside screening can come off the outreach list, with the source document in the ZAP as evidence. The rest are your outreach list.

Result: a shorter, more accurate outreach list, and evidence for screenings done elsewhere.

Find patients with uncontrolled diabetes

Goal: find patients whose latest HbA1c is above 9%, including results from outside labs.

1. Run the HbA1c > 9% query in Identifying care gaps. It uses LOINC-coded A1C results from all sources.
2. Each row shows when the result was taken, the visit type it came from (using the Encounter Lens) and whether EHR documentation is available.
3. Route the list to care managers. They can open each patient's ZAP to see recent visits and medication fills before calling.

Result: a list of patients to engage on glycemic control, built from results your EHR may not have.

Catch missed refills

Goal: spot patients who have stopped filling a medication, while there's still time to help.

1. For medications tied to a CMS eCQM or HEDIS measure, Zus refreshes pharmacy history no more than 7 days after the expected refill date. See Pharmacy Network.
2. Run the missed refills query. It finds each patient's latest fill for each medication and compares the days since that fill with the days of supply.
3. Reach out to the flagged patients about cost, side effects or other barriers.

Result: earlier outreach on adherence, based on actual pharmacy fills.

More queries

Identifying care gaps also has queries for high blood pressure and kidney health evaluation (eGFR and uACR) for patients with diabetes. Atlas can be configured to return care gap inputs, each with a citation to its source.

In the clinical guide

• Quality Gap Closure: how care teams and analysts use Zus data for quality work

Related pages

• Query Library
• Population Health Management
• Risk Adjustment