GoalIdentificationMeasure
type: Measure
node role: treeRoot
id:
  v: GoalIdentificationMeasure
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: Knowledge Artifact Metadata Name (machine-readable) GoalIdentificationMeasure Title (human-readable) Person-Centered Goal Identification Status Draft Experimental true Description Measure 1 - Goal Identification: % of individuals 18 years of age and older with a complex care need who had a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan. 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, incorporatin…
contained: Library
  id:
    v: effective-data-requirements
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode
      l: cqf-directReferenceCode
    value: Coding
      system:
        v: http://hl7.org/fhir/us/pco/CodeSystem/pco-concepts-temporary
        l: pco-concepts-temporary
      code:
        v: what-matters
      display:
        v: What Matters
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode
      l: cqf-directReferenceCode
    value: Coding
      type: https://loinc.org/rdf/107332-9
      system:
        v: http://loinc.org
        l: loinc.org
      code:
        v: 107332-9
      display:
        v: Goal attainment scale - Reported
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GoalIdentificationMeasure
    extension:
      url:
        v: name
        l: name
      value: String
        v: Initial Population
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: /* Goal Identification: % of individuals 18 years of age and older with a complex care need who had a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan. */ /* @description: Includes individuals 18 years of age and older. */ define "Initial Population": { Patient person where AgeInYearsAt(start of "Measurement Period") >= 18 }
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 0
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GoalIdentificationMeasure
    extension:
      url:
        v: name
        l: name
      value: String
        v: Denominator
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: /* @description: Initial Population individuals with a complex care need. @comment: TODO - How do we determine "complex care need?" */ define "Denominator": "Initial Population"
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 1
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: WhatMattersLogic
    extension:
      url:
        v: name
        l: name
      value: String
        v: Well-Being Observations
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: define "Well-Being Observations": [Observation] obs where obs.category in "Well-Being Categories" or obs.code in "Well-Being Domains"
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 2
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GoalAttainmentLogic
    extension:
      url:
        v: name
        l: name
      value: String
        v: PCO Goals
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: /* 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
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 3
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GoalAttainmentLogic
    extension:
      url:
        v: name
        l: name
      value: String
        v: GAS Scores
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: // Observations containing a GAS score. define "GAS Scores": [Observation: "Goal Attainment Scaling (GAS) Score"]
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 4
    url:
      v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
      l: cqf-logicDefinition
  extension:
    extension:
      url:
        v: libraryName
        l: libraryName
      value: String
        v: GoalAttainmentLogic
    extension:
      url:
        v: name
        l: name
      value: String
        v: PCO Goals During Measurement Period
    extension:
      url:
        v: statement
        l: statement
      value: String
        v: // 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()
    extension:
      url:
        v: displaySequence
        l: displaySequence
      value: Integer
        v: 5

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: PROM Scores
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // Observations containing a PROM score. define "PROM Scores": [Observation: "PROM Target Measures"]
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 6
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: Baseline Scores Before Follow-Up Period
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* Baseline Scares are PCO score observations taken during the Measurement Period, but before the follow-up period for its Goal. Default follow-up period is 2 weeks to 6 months following the goal startDate. */ define "Baseline Scores Before Follow-Up 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 before start of "Follow-Up Interval For"(goal)) )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 7
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalIdentificationMeasure
extension:
  url:
    v: name
    l: name
  value: String
    v: Numerator
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* ... has a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan. */ define "Numerator": "Denominator" person where exists PCOLogic."PCO Goals During Measurement Period" and exists PCOLogic."Baseline Scores Before Follow-Up Period"
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 8
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalIdentificationMeasure
extension:
  url:
    v: name
    l: name
  value: String
    v: Denominator Exclusions
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Denominator Exclusions": null
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 9
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalIdentificationMeasure
extension:
  url:
    v: name
    l: name
  value: String
    v: Denominator Exceptions
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define "Denominator Exceptions": null
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 10
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: FHIRHelpers
extension:
  url:
    v: name
    l: name
  value: String
    v: ToConcept
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* @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 }
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 11
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: WhatMattersLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: whatMattersObservations
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // 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() )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 12
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: FHIRHelpers
extension:
  url:
    v: name
    l: name
  value: String
    v: ToString
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define function ToString(value string): value.value
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 13
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: PCOCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: getId
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define fluent function getId(uri String): Last(Split(uri, '/'))
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 14
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: WhatMattersLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: isWhatMatters
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define fluent function isWhatMatters(obs Observation): exists( "Well-Being Observations" obs where exists(obs.category cat where cat = "What Matters category") )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 15
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: FHIRHelpers
extension:
  url:
    v: name
    l: name
  value: String
    v: ToDate
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define function ToDate(value date): value.value
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 16
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: hasGAS
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // 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()
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 17
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: PCOCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: extensions
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* @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
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 18
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: gasScores
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // Returns a list of Observation including only GAS scores define fluent function gasScores(goal Goal): "GAS Scores" score where score.focusGoals() contains goal
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 19
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: focusGoals
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // Returns a list of Goal where focus includes the given Observation. define fluent function focusGoals(obs Observation): obs.focus.resolveGoals()
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 20
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: PCOCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: resolveGoals
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define fluent function resolveGoals(references List<Reference>): flatten( references ref return [Goal] resource where resource.id = ref.reference.getId() )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 21
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: hasPROM
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /// 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" )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 22
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: PCOCommon
extension:
  url:
    v: name
    l: name
  value: String
    v: carePlans
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // 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() )
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 23
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: pcoScores
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // Returns a list of Observation including both GAS and PROM scores define fluent function pcoScores(goal Goal): goal.gasScores() union goal.promScores()
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 24
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: promScores
extension:
  url:
    v: statement
    l: statement
  value: String
    v: // Returns a list of Observation including only PROM scores define fluent function promScores(goal Goal): "PROM Scores" score where score.focusGoals() contains goal
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 25
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: FHIRHelpers
extension:
  url:
    v: name
    l: name
  value: String
    v: ToDateTime
extension:
  url:
    v: statement
    l: statement
  value: String
    v: define function ToDateTime(value dateTime): value.value
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 26
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

extension:
  url:
    v: libraryName
    l: libraryName
  value: String
    v: GoalAttainmentLogic
extension:
  url:
    v: name
    l: name
  value: String
    v: Follow-Up Interval For
extension:
  url:
    v: statement
    l: statement
  value: String
    v: /* 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")
extension:
  url:
    v: displaySequence
    l: displaySequence
  value: Integer
    v: 27
url:
  v: http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition
  l: cqf-logicDefinition

v: EffectiveDataRequirements

v: active

coding:
  system:
    v: http://terminology.hl7.org/CodeSystem/library-type
    l: library-type
  code:
    v: module-definition

type:
  v: depends-on
display:
  v: Library PCOLogic
resource:
  v: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0
  l: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic

type:
  v: depends-on
display:
  v: Library FHIRHelpers
resource:
  v: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
  l: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers

type:
  v: depends-on
display:
  v: Library WM
resource:
  v: http://hl7.org/fhir/us/pco/Library/WhatMattersLogic|0.1.0
  l: http://hl7.org/fhir/us/pco/Library/WhatMattersLogic

type:
  v: depends-on
display:
  v: Library PC
resource:
  v: http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0
  l: http://hl7.org/fhir/us/pco/Library/PCOCommon

type:
  v: depends-on
display:
  v: Code system Well-Being Concepts
resource:
  v: http://hl7.org/fhir/us/pco/CodeSystem/pco-concepts-temporary
  l: pco-concepts-temporary

type:
  v: depends-on
display:
  v: Code system LOINC
resource:
  v: http://loinc.org
  l: loinc.org

type:
  v: depends-on
display:
  v: Value set Well-Being Categories
resource:
  v: http://hl7.org/fhir/us/pco/ValueSet/pco-categories
  l: pco-categories

type:
  v: depends-on
display:
  v: Value set PCO Goal Domain Categories
resource:
  v: http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domain-categories
  l: pco-goal-domain-categories

type:
  v: depends-on
display:
  v: Value set Well-Being Domains
resource:
  v: http://hl7.org/fhir/us/pco/ValueSet/wellbeing-domains-example
  l: wellbeing-domains-example

type:
  v: depends-on
display:
  v: Value set Goal Attainment Scaling (GAS) Score
resource:
  v: http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score
  l: goal-attainment-scaling-score

type:
  v: depends-on
display:
  v: Value set PROM Target Measures
resource:
  v: http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures
  l: prom-target-measures

name:
  v: Measurement Period
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: Period

name:
  v: Follow-Up Interval
use:
  v: in
min:
  v: 0
max:
  v: 1
type:
  v: Range

name:
  v: Numerator
use:
  v: out
min:
  v: 0
max:
  v: *
type:
  v: Patient

name:
  v: Denominator
use:
  v: out
min:
  v: 0
max:
  v: *
type:
  v: Patient

name:
  v: Initial Population
use:
  v: out
min:
  v: 0
max:
  v: *
type:
  v: Patient

name:
  v: Denominator Exclusions
use:
  v: out
min:
  v: 0
max:
  v: 1
type:
  v: Resource

name:
  v: Denominator Exceptions
use:
  v: out
min:
  v: 0
max:
  v: 1
type:
  v: Resource

type:
  v: Patient
profile:
  v: http://hl7.org/fhir/StructureDefinition/Patient
  l: Patient

type:
  v: Observation
profile:
  v: http://hl7.org/fhir/StructureDefinition/Observation
  l: Observation
must support:
  v: category
must support:
  v: code
must support:
  v: id

type:
  v: Observation
profile:
  v: http://hl7.org/fhir/StructureDefinition/Observation
  l: Observation
must support:
  v: code
code filter:
  path:
    v: code
  value set:
    v: http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score
    l: goal-attainment-scaling-score

type:
  v: Observation
profile:
  v: http://hl7.org/fhir/StructureDefinition/Observation
  l: Observation
must support:
  v: code
code filter:
  path:
    v: code
  value set:
    v: http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures
    l: prom-target-measures

type:
  v: Goal
profile:
  v: http://hl7.org/fhir/StructureDefinition/Goal
  l: Goal
must support:
  v: category
must support:
  v: start
must support:
  v: reference
must support:
  v: measure
must support:
  v: id

type:
  v: CarePlan
profile:
  v: http://hl7.org/fhir/StructureDefinition/CarePlan
  l: CarePlan
must support:
  v: goal

id:
  v: effective-data-requirements
url:
  v: http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements
  l: crmi-effectiveDataRequirements
value: Canonical
  v: #effective-data-requirements
  l: effective-data-requirements

url:
  v: http://hl7.org/fhir/StructureDefinition/structuredefinition-wg
  l: structuredefinition-wg
value: Code
  v: pc

v: 1.0.0

v: GoalIdentificationMeasure

v: Person-Centered Goal Identification

v: draft

v: true

v: 2025-02-12T18:05:49+00:00

v: HL7 International / Patient Care

name:
  v: HL7 International / Patient Care
telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/patientcare
telecom:
  system:
    v: email

v: Measure 1 - Goal Identification: % of individuals 18 years of age and older with a complex care need who had a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan.

coding:
  system:
    v: urn:iso:std:iso:3166
    l: 3166
  code:
    v: US
  display:
    v: United States of America

v: 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.

v: Content TBD.

v: 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.

start:
  v: 2024-01-01
end:
  v: 2024-12-31

name:
  v: HL7 International / Patient Care
telecom:
  system:
    v: url
  value:
    v: http://www.hl7.org/Special/committees/patientcare

v: 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.

coding:
  system:
    v: http://terminology.hl7.org/CodeSystem/measure-scoring
    l: measure-scoring
  code:
    v: proportion
  display:
    v: Proportion

v: 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.

v: None at this time.

id:
  v: 64f0d91d56d636294b157d97
description:
  v: Content TBD
population:
  code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/measure-population
        l: measure-population
      code:
        v: initial-population
      display:
        v: Initial Population
  description:
    v: Individuals 18 years of age and older.
  criteria:
    language:
      v: text/cql-identifier
    expression:
      v: Initial Population
population:
  code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/measure-population
        l: measure-population
      code:
        v: denominator
      display:
        v: Denominator
  description:
    v: Individuals 18 years of age and older with a complex care need.
  criteria:
    language:
      v: text/cql-identifier
    expression:
      v: Denominator
population:
  code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/measure-population
        l: measure-population
      code:
        v: denominator-exclusion
      display:
        v: Denominator Exclusion
  description:
    v: None
  criteria:
    language:
      v: text/cql-identifier
    expression:
      v: Denominator Exclusions
population:
  code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/measure-population
        l: measure-population
      code:
        v: numerator
      display:
        v: Numerator
  description:
    v: Individuals who had a PCO goal identified resulting in completion of goal attainment scaling (GAS) or a Patient-Reported Outcome Measure (PROM) and development of an action plan.
  criteria:
    language:
      v: text/cql-identifier
    expression:
      v: Numerator
population:
  code:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/measure-population
        l: measure-population
      code:
        v: denominator-exception
      display:
        v: Denominator Exception
  description:
    v: None
  criteria:
    language:
      v: text/cql-identifier
    expression:
      v: Denominator Exceptions