Knowledge Artifact Metadata Name (machine-readable) GoalFollowUpMeasure Title (human-readable) Person-Centered Goal Follow-Up Status Draft Experimental true 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. Purpose Goal Attainment Scaling (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. Clinical Usage Content TBD. Effective Period 2024-01-01..2024-12-31 Measure Developer HL7 International / Patient Care: http://www.hl7.org/Special/committees/patientcare Measure Steward HL7 International / Patient Care Steward Contact Details HL7 International / Patient Care: http://www.hl7.org/Special/committees/patientcare,patientcare@lists.HL7.org Copyright Measure definition is copyright 2024 by NCQA. LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved. Measure Metadata Version Number 1.0.0 Measure Scoring Proportion Rationale Goal-directed care in healthcare centers 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 individual 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. Clinical Recommendation Statement None at this time. Measure Population Criteria (ID: 64f0d91d56d636294b157d97) Summary Content TBD Initial Population ID: 692C6F6B-4153-496F-8582-0839A0816567 Description: Individuals 18 years of age and older. Logic Definition: Initial Population Denominator ID: 3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9 Description: Individuals 18 years of age and older with a complex care need and has a PCO Goal. Logic Definition: Denominator Denominator Exclusion ID: AA76FF0E-0EF9-40E6-9913-90FA63D50298 Description: None Logic Definition: Denominator Exclusions Numerator ID: 3D2BED97-5ADC-4210-8A3E-91B13652E7D0 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. Logic Definition: Numerator Denominator Exception ID: 4511743B-B054-4A08-800B-C4624450C38C Description: None Logic Definition: Denominator Exceptions Measure Logic Primary Library GoalFollowUpMeasure Dependency Description: Library PCOLogic Resource: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0 Canonical URL: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0 Dependency Description: Library FHIRHelpers Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Dependency Description: Library WM Resource: http://hl7.org/fhir/us/pco/Library/WhatMattersLogic|0.1.0 Canonical URL: http://hl7.org/fhir/us/pco/Library/WhatMattersLogic|0.1.0 Dependency Description: Library PC Resource: http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0 Canonical URL: http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0 Dependency Description: Code system Well-Being Concepts Resource: Person-Centered Outcome Concepts Canonical URL: http://hl7.org/fhir/us/pco/CodeSystem/pco-concepts-temporary Dependency Description: Code system LOINC Resource: Logical Observation Identifiers, Names and Codes (LOINC) Canonical URL: http://loinc.org Dependency Description: Value set Well-Being Categories Resource: Person-Centered Categories Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/pco-categories Dependency Description: Value set PCO Goal Domain Categories Resource: PCO Goal Domain Categories Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories Dependency Description: Value set Well-Being Domains Resource: Well-Being Domains Example Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/wellbeing-domains-example Dependency Description: Value set Goal Attainment Scaling (GAS) Score Resource: Goal Attainment Scaling (GAS) Score Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score Dependency Description: Value set PROM Target Measures Resource: PROM Target Measure Scores Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures Direct Reference Code Display: What Matters Code: what-matters System: http://hl7.org/fhir/us/pco/CodeSystem/pco-concepts-temporary Direct Reference Code Display: Goal attainment scale - Reported Code: 107332-9 System: http://loinc.org Parameter Name: Measurement Period Use: In Min Cardinality: 0 Max Cardinality: 1 Type: Period Parameter Name: Follow-Up Interval Use: In Min Cardinality: 0 Max Cardinality: 1 Type: Range Parameter Name: Numerator Use: Out Min Cardinality: 0 Max Cardinality: * Type: Patient Parameter Name: Denominator Use: Out Min Cardinality: 0 Max Cardinality: * Type: Patient Parameter Name: Initial Population Use: Out Min Cardinality: 0 Max Cardinality: * Type: Patient Parameter Name: Denominator Exclusions Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: Resource Parameter Name: Denominator Exceptions Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: Resource Measure Logic Data Requirements Data Requirement Type: Patient Profile(s): Patient Data Requirement Type: Observation Profile(s): Observation Must Support Elements: category, code, id Data Requirement Type: Observation Profile(s): Observation Must Support Elements: code Code Filter(s): Path: code ValueSet: Goal Attainment Scaling (GAS) Score Data Requirement Type: Observation Profile(s): Observation Must Support Elements: code Code Filter(s): Path: code ValueSet: PROM Target Measure Scores Data Requirement Type: Goal Profile(s): Goal Must Support Elements: category, start, reference, measure, id Data Requirement Type: CarePlan Profile(s): CarePlan Must Support Elements: goal Measure Logic Definitions Logic Definition Library Name: GoalFollowUpMeasure /* @description: Includes individuals 18 years of age and older. */ define "Initial Population": { Patient person where AgeInYearsAt(start of "Measurement Period") >= 18 } Logic Definition Library Name: GoalFollowUpMeasure /* @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" Logic Definition Library Name: WhatMattersLogic define "Well-Being Observations": [Observation] obs where obs.category in "Well-Being Categories" or obs.code in "Well-Being Domains" Logic Definition Library Name: GoalAttainmentLogic /* A "PCO Goal" is any FHIR Goal that has a category in "What Matters Category" or "PCO Domain Categories" or that addresses a What Matters observation and has a start date. */ define "PCO Goals": [Goal] goal where (goal.category in WM."Well-Being Categories" or goal.category in "PCO Goal Domain Categories" or exists goal.whatMattersObservations()) and (goal.start as FHIR.date) is not null Logic Definition Library Name: GoalAttainmentLogic // Observations containing a GAS score. define "GAS Scores": [Observation: "Goal Attainment Scaling (GAS) Score"] Logic Definition Library Name: GoalAttainmentLogic // PCO Goals whose startDate falls within the Measurement Period define "PCO Goals During Measurement Period": "PCO Goals" goal where (ToDateTime(goal.start as FHIR.date) during "Measurement Period") and (goal.hasGAS() or goal.hasPROM()) and exists goal.carePlans() Logic Definition Library Name: GoalAttainmentLogic // Observations containing a PROM score. define "PROM Scores": [Observation: "PROM Target Measures"] Logic Definition Library Name: GoalAttainmentLogic /* Follow-Up Scares are PCO score observations taken during the Measurement Period, and during the follow-up period for its Goal. Default follow-up period is 2 weeks to 6 months following the goal startDate. */ define "Follow-Up Scores During Measurement Period": flatten( "PCO Goals During Measurement Period" goal let pcoScores: goal.pcoScores() return pcoScores score let scoreDate: score.effective as FHIR.dateTime where scoreDate during "Measurement Period" and scoreDate during "Follow-Up Interval For"(goal) ) Logic Definition Library Name: GoalFollowUpMeasure /* @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" Logic Definition Library Name: GoalFollowUpMeasure define "Denominator Exclusions": null Logic Definition Library Name: GoalFollowUpMeasure define "Denominator Exceptions": null Logic Definition Library Name: FHIRHelpers /* @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept. */ define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value } Logic Definition Library Name: WhatMattersLogic // Returns a list of what matters Observations this Goal addresses. define fluent function whatMattersObservations(goal Goal): flatten( goal.addresses GA return [Observation] obs where obs.id = GA.reference.getId() and obs.isWhatMatters() ) Logic Definition Library Name: FHIRHelpers define function ToString(value string): value.value Logic Definition Library Name: PCOCommon define fluent function getId(uri String): Last(Split(uri, '/')) Logic Definition Library Name: WhatMattersLogic define fluent function isWhatMatters(obs Observation): exists( "Well-Being Observations" obs where exists(obs.category cat where cat = "What Matters category") ) Logic Definition Library Name: FHIRHelpers define function ToDate(value date): value.value Logic Definition Library Name: GoalAttainmentLogic // where exists obs.performer.resolveRelatedPersons() define fluent function hasGAS(goal Goal): exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling') or exists (goal.target target where target.measure = "Goal attainment scale" ) or exists goal.gasScores() Logic Definition Library Name: PCOCommon /* @description: Returns any extensions defined on the given resource with the specified url. @comment: NOTE: Extensions are not the preferred approach, but are used as a way to access content that is defined by extensions but not yet surfaced in the CQL model info. */ define fluent function extensions(domainResource DomainResource, url String): domainResource.extension E where E.url = url return E Logic Definition Library Name: GoalAttainmentLogic // Returns a list of Observation including only GAS scores define fluent function gasScores(goal Goal): "GAS Scores" score where score.focusGoals() contains goal Logic Definition Library Name: GoalAttainmentLogic // Returns a list of Goal where focus includes the given Observation. define fluent function focusGoals(obs Observation): obs.focus.resolveGoals() Logic Definition Library Name: PCOCommon define fluent function resolveGoals(references List<Reference>): flatten( references ref return [Goal] resource where resource.id = ref.reference.getId() ) Logic Definition Library Name: GoalAttainmentLogic /// Returns true if this Goal has a PROM code in its target.measure define fluent function hasPROM(goal Goal): exists (goal.target target where target.measure in "PROM Target Measures" ) Logic Definition Library Name: PCOCommon // Returns a list of CarePlan that support this Goal. define fluent function carePlans(goal Goal): [CarePlan] carePlan where exists ( carePlan.goal goalRef where goal.id = goalRef.reference.getId() ) Logic Definition Library Name: GoalAttainmentLogic // Returns a list of Observation including both GAS and PROM scores define fluent function pcoScores(goal Goal): goal.gasScores() union goal.promScores() Logic Definition Library Name: GoalAttainmentLogic // Returns a list of Observation including only PROM scores define fluent function promScores(goal Goal): "PROM Scores" score where score.focusGoals() contains goal Logic Definition Library Name: FHIRHelpers define function ToDateTime(value dateTime): value.value Logic Definition Library Name: GoalAttainmentLogic /* Computes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter. @return Interval<DateTime> */ define function "Follow-Up Interval For" (goal Goal): goal goal let startDate: ToDateTime(goal.start as FHIR.date) return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval") Generated using version 0.4.6 of the sample-content-ig Liquid templates
/* @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 "Well-Being Observations": [Observation] obs where obs.category in "Well-Being Categories" or obs.code in "Well-Being Domains"
/* A "PCO Goal" is any FHIR Goal that has a category in "What Matters Category" or "PCO Domain Categories" or that addresses a What Matters observation and has a start date. */ define "PCO Goals": [Goal] goal where (goal.category in WM."Well-Being Categories" or goal.category in "PCO Goal Domain Categories" or exists goal.whatMattersObservations()) and (goal.start as FHIR.date) is not null
// Observations containing a GAS score. define "GAS Scores": [Observation: "Goal Attainment Scaling (GAS) Score"]
// PCO Goals whose startDate falls within the Measurement Period define "PCO Goals During Measurement Period": "PCO Goals" goal where (ToDateTime(goal.start as FHIR.date) during "Measurement Period") and (goal.hasGAS() or goal.hasPROM()) and exists goal.carePlans()
// Observations containing a PROM score. define "PROM Scores": [Observation: "PROM Target Measures"]
Follow-Up Scores During Measurement Period
/* Follow-Up Scares are PCO score observations taken during the Measurement Period, and during the follow-up period for its Goal. Default follow-up period is 2 weeks to 6 months following the goal startDate. */ define "Follow-Up Scores During Measurement Period": flatten( "PCO Goals During Measurement Period" goal let pcoScores: goal.pcoScores() return pcoScores score let scoreDate: score.effective as FHIR.dateTime where scoreDate during "Measurement Period" and scoreDate during "Follow-Up Interval For"(goal) )
/* @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"
/* @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept. */ define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value }
// Returns a list of what matters Observations this Goal addresses. define fluent function whatMattersObservations(goal Goal): flatten( goal.addresses GA return [Observation] obs where obs.id = GA.reference.getId() and obs.isWhatMatters() )
define function ToString(value string): value.value
define fluent function getId(uri String): Last(Split(uri, '/'))
define fluent function isWhatMatters(obs Observation): exists( "Well-Being Observations" obs where exists(obs.category cat where cat = "What Matters category") )
define function ToDate(value date): value.value
// where exists obs.performer.resolveRelatedPersons() define fluent function hasGAS(goal Goal): exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling') or exists (goal.target target where target.measure = "Goal attainment scale" ) or exists goal.gasScores()
/* @description: Returns any extensions defined on the given resource with the specified url. @comment: NOTE: Extensions are not the preferred approach, but are used as a way to access content that is defined by extensions but not yet surfaced in the CQL model info. */ define fluent function extensions(domainResource DomainResource, url String): domainResource.extension E where E.url = url return E
// Returns a list of Observation including only GAS scores define fluent function gasScores(goal Goal): "GAS Scores" score where score.focusGoals() contains goal
// Returns a list of Goal where focus includes the given Observation. define fluent function focusGoals(obs Observation): obs.focus.resolveGoals()
define fluent function resolveGoals(references List<Reference>): flatten( references ref return [Goal] resource where resource.id = ref.reference.getId() )
/// Returns true if this Goal has a PROM code in its target.measure define fluent function hasPROM(goal Goal): exists (goal.target target where target.measure in "PROM Target Measures" )
// Returns a list of CarePlan that support this Goal. define fluent function carePlans(goal Goal): [CarePlan] carePlan where exists ( carePlan.goal goalRef where goal.id = goalRef.reference.getId() )
// Returns a list of Observation including both GAS and PROM scores define fluent function pcoScores(goal Goal): goal.gasScores() union goal.promScores()
// Returns a list of Observation including only PROM scores define fluent function promScores(goal Goal): "PROM Scores" score where score.focusGoals() contains goal
define function ToDateTime(value dateTime): value.value
/* Computes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter. @return Interval<DateTime> */ define function "Follow-Up Interval For" (goal Goal): goal goal let startDate: ToDateTime(goal.start as FHIR.date) return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval")
Value set Goal Attainment Scaling (GAS) Score
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.
Goal Attainment Scaling (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.
Measure definition is copyright 2024 by NCQA. LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.
These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.
Goal-directed care in healthcare centers 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 individual 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.
Individuals 18 years of age and older with a complex care need and has a PCO Goal.
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.