Person-Centered Outcomes (PCO) Implementation Guide
1.0.0 - STU 1 United States of America flag

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 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

Library: GoalFollowUpMeasure

Official URL: http://hl7.org/fhir/us/pco/Library/GoalFollowUpMeasure Version: 1.0.0
Standards status: Draft Maturity Level: 2 Computable Name: GoalFollowUpMeasure

CQL logic for the Goal Follow-up Measure

Id: GoalFollowUpMeasure
Version: 1.0.0
Url: GoalFollowUpMeasure
Status: draft
Type:

system: http://terminology.hl7.org/CodeSystem/library-type

code: logic-library

Date: 2025-08-26 15:38:43+0000
Publisher: HL7 International / Patient Care
Description:

CQL logic for the Goal Follow-up Measure
Jurisdiction: US
Related Artifacts:

Dependencies
Parameters:
NameTypeMinMaxIn/Out
Measurement PeriodPeriod01In
Follow-Up IntervalRange01In
PatientPatient01Out
Initial PopulationPatient0*Out
DenominatorPatient0*Out
Denominator ExclusionsResource01Out
Denominator ExceptionsResource01Out
NumeratorPatient0*Out
Data Requirements:
TypeProfileMSCode Filter
Patient http://hl7.org/fhir/StructureDefinition/Patient
Content: text/cql
/*
@description: Measure 2 - Goal Follow-up: % of individuals 18 years of age or older with
a complex care need who received follow-up on their PCO goal within two
weeks to six months of when the PCO goal and GAS or PROM were
identified.

@author: Mountain Lotus WellBeing LLC
*/
library GoalFollowUpMeasure version '0.1.0'

using FHIR version '4.0.1'

include hl7.fhir.uv.cql.FHIRCommon version '2.0.0'
include hl7.fhir.uv.cql.FHIRHelpers version '4.0.1'
include PCOCommon version '0.1.0' called PC
include GoalAttainmentLogic version '0.1.0' called PCOLogic

parameter "Measurement Period" Interval<DateTime>
    default Interval[@2024-01-01T00:00:00.000Z, @2024-12-31T23:59:59.999Z]

parameter "Follow-Up Interval" Interval<System.Quantity>
  default Interval[2 weeks, 26 weeks]

context Patient

/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
  Patient person
    where AgeInYearsAt(start of "Measurement Period") >= 18
}

/*
@description: Initial Population individuals with a complex care need and has a PCO Goal.
@comment: TODO - How do we determine "complex care need?"
*/
define "Denominator":
  "Initial Population"

define "Denominator Exclusions":
  null

define "Denominator Exceptions":
  null

/*
@description: Indivuals who received follow-up on their PCO goal within two
weeks to six months of when the PCO goal and GAS or PROM were identified.
*/
define "Numerator":
  "Denominator" person
    where exists PCOLogic."Follow-Up Scores During Measurement Period"
Content: application/elm+xml
Encoded data (21252 characters)
Content: application/elm+json
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