Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - ballot
Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - ballot
Person-Centered Outcomes (PCO) Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/pco-ig/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/pco/ImplementationGuide/hl7.fhir.us.pco | Version: 1.0.0-ballot | |||
| IG Standards status: Draft | Maturity Level: 2 | Computable Name: PCO | ||
The Person-Centered Outcomes (PCO) HL7® FHIR® Implementation Guide (IG) supports the exchange of information related to person-centered care guided by a person-centered outcomes approach, which includes the identification and tracking of personal outcome goals that matter most to patients using either Goal Attainment Scaling (GAS) or patient-reported outcome measures (PROM).
The PCO IG includes profiles for interoperable GAS Goals, support for goal editing tools, and PCO measures. GAS in healthcare measures the extent to which individuals achieve specific goals or objectives. It allows for the quantification and evaluation of progress toward individualized goals, particularly in areas where traditional outcome measures may be insufficient. GAS involves collaboratively setting goals with the individual and assigning numerical scales to each goal to represent different levels of achievement. This approach provides a more nuanced and tailored way to assess progress and outcomes, taking into account the unique circumstances and aspirations of the individual.
The "Plain Language Summary about HL7 and this Guide" is an experimental section that potentially could become a required part of HL7 FHIR implementation guides. The PCO IG team has agreed to incorporate this in the PCO guide and as part of ballot and ask for:
HL7, which stands for Health Level Seven, creates standards to help different healthcare computer systems share information. One of the HL7 standards is HL7 FHIR (Fast Healthcare Interoperability Resources). It helps connect healthcare systems and applications used by clinicians and patients to share a wide range of information about their care that could include health conditions, medications, health goals, patient surveys, and much more.
The HL7 FHIR Person-Centered Outcomes (PCO) FHIR Implementation Guide (IG) helps healthcare technology experts design systems that help doctors, health coaches, and other healthcare providers focus on what matters most to each person receiving care. It provides a standard way for healthcare systems to share and track information about a patient's personal health goals and outcomes.
This guide supports two ways of measuring progress on person-centered goals:
Many people, especially older adults and those with complex health needs, receive care that does not always match their personal goals. More than 14 million people in the U.S. need long-term care, and nearly 30% of Medicare patients have complex health conditions. This guide helps ensure that clinical and social care focuses on each person's unique goals—whether that’s being able to walk without pain, spending time with family, or managing a chronic condition effectively. As health care moves toward more personalized care and new payment models, we need clear standards for tracking and reporting patient goals. This guide helps care providers, researchers, and policymakers make sure care is truly centered on what each person wants and needs.
Goal-directed care is about working together to set and reach personal goals. It includes:
This guide helps different health IT systems and apps work together by setting clear standards for sharing and using goal-related data. It provides:
This guide is useful for:
Everyone deserves fair and just access to high-quality healthcare that addresses their unique needs, reflects their diverse background and culture, and is designed to deliver the outcomes they want. This is particularly true for people with complex healthcare needs, many of whom are older adults who often receive care that may be misaligned with their needs and goals. Nearly 30% of Medicare beneficiaries have complex healthcare needs, and more than 14 million people in the U.S. need long-term services and supports. These numbers are growing every year.
Goal-directed care in healthcare focuses on setting and achieving specific, personalized goals that prioritize an individual's well-being and "What Matters Most" to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify personalized goals related to health outcomes, functional improvement, or symptom management. Once goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness.
The Person-Centered Outcomes (PCO) approach focuses on setting and achieving specific, personalized, measurable goals that prioritize an individual's well-being and "What Matters Most" to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify personalized goals related to health outcomes, functional improvement, or symptom management. After goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness. Clinicians throughout the care continuum—from primary care to specialty care, to home and community-based services—can use this approach to identify what is important to a person (e.g., feeling well enough to visit grandchildren). This approach and its coordinating measures can help support and assess the quality of goal-directed care being implemented.
The need for the PCO IG was identified as a natural next step from the scope of the MCC eCare Plan FHIR IG STU1 which provided high-level guidance for goals and measuring outcomes. As goal-directed care is growing in use and being incorporated into payment programs, the need for data standards around implementation and reporting are necessary. This IG supports implementers, researchers, patients, and evaluators of goal-directed care planning to improve person-centered outcomes.
Several user stories are included in this guide that align with steps in the following process flow diagram. The stories are written to support user-centered design of systems from the point-of-view of patients, health coaches, and clinicians.
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This IG is divided into several sections that are listed at the top of each page in the menu bar.
This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (hl7.fhir.us.pco.r4) and R4B (hl7.fhir.us.pco.r4b) are available.
IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pco#1.0.0-ballot based on FHIR 4.0.1. Generated 2025-03-20
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