Person-Centered Outcomes
0.2.0 - ci-build
Person-Centered Outcomes
0.2.0 - ci-build
Person-Centered Outcomes, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/mtnlotus/pco-ig/ and changes regularly. See the Directory of published versions
| Active as of 2024-12-11 |
{
"resourceType" : "Measure",
"id" : "GoalFollowUpMeasure",
"meta" : {
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🔗 "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"🔗 ,
"http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm"🔗 ,
"http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table class=\"narrative-table\">\n <tbody>\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Knowledge Artifact Metadata</th>\n\n</tr>\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Name (machine-readable)</th>\n\n<td class=\"content-container\">GoalFollowUpMeasure</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Title (human-readable)</th>\n\n<td class=\"content-container\">Person-Centered Goal Follow-Up</td>\n</tr>\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Status</th>\n\n<td class=\"content-container\">Active</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Experimental</th>\n\n<td class=\"content-container\">false</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Description</th>\n\n<td class=\"content-container\"><div><p>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.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Purpose</th>\n\n<td class=\"content-container\"><div><p>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.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Clinical Usage</th>\n\n<td class=\"content-container\">Content TBD.</td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Effective Period</th>\n\n<td class=\"content-container\">2024-01-01..2024-12-31</td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Developer</th>\n\n<td class=\"content-container\">HL7 International / Patient Care: <a href=\"http://www.hl7.org/Special/committees/patientcare\">http://www.hl7.org/Special/committees/patientcare</a></td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Steward</th>\n\n<td class=\"content-container\">HL7 International / Patient Care</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Steward Contact Details</th>\n\n<td class=\"content-container\">HL7 International / Patient Care: <a href=\"http://www.hl7.org/Special/committees/patientcare\">http://www.hl7.org/Special/committees/patientcare</a>,<a href=\"mailto:patientcare@lists.HL7.org\">patientcare@lists.HL7.org</a></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Copyright</th>\n\n<td class=\"content-container\"><div><p>Measure definition is copyright 2024 by NCQA.</p>\n<p>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.</p>\n</div></td>\n</tr>\n\n\n\n\n\n\n\n\n\n\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Metadata</th>\n\n</tr>\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Short Name Identifier</th>\n\n<td class=\"content-container\">PCOMeasure1</td>\n</tr>\n\n\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Independent Identifier</th>\n\n<td class=\"content-container\">urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328</td>\n</tr>\n\n\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Specific Identifier</th>\n\n<td class=\"content-container\">urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05</td>\n</tr>\n\n\n\n \n \n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Publisher (CMS) Identifier</th>\n\n<td class=\"content-container\">NA</td>\n</tr>\n\n \n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Number</th>\n\n<td class=\"content-container\">0.2.0</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Scoring</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-scoring proportion}\">Proportion</span></td>\n</tr>\n\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Rationale</th>\n\n<td class=\"content-container\"><div><p>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.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Clinical Recommendation Statement</th>\n\n<td class=\"content-container\"><div><p>None at this time.</p>\n</div></td>\n</tr>\n\n\n\n\n\n\n\n\n\n \n \n <tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Population Criteria (ID: 64f0d91d56d636294b157d97)</th>\n\n</tr>\n \n \n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Summary</th>\n\n<td class=\"content-container\">Content TBD</td>\n</tr>\n\n \n \n \n <tr>\n \n \n<th scope=\"row\" class=\"row-header\">Initial Population</th>\n\n \n <td class=\"content-container\">\n \n <em>ID</em>: 692C6F6B-4153-496F-8582-0839A0816567\n <br/>\n \n \n <em>Description</em>:\n <p style=\"white-space: pre-line\" class=\"tab-one\">Individuals 18 years of age and older.</p>\n \n \n \n \n <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-initial-population\">Initial Population</a> \n \n \n </td>\n </tr>\n \n\n \n <tr>\n \n \n<th scope=\"row\" class=\"row-header\">Denominator</th>\n\n \n <td class=\"content-container\">\n \n <em>ID</em>: 3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9\n <br/>\n \n \n <em>Description</em>:\n <p style=\"white-space: pre-line\" class=\"tab-one\">Individuals 18 years of age and older with a complex care need and has a PCO Goal.</p>\n \n \n \n \n <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator\">Denominator</a> \n \n \n </td>\n </tr>\n \n\n \n <tr>\n \n \n<th scope=\"row\" class=\"row-header\">Denominator Exclusion</th>\n\n \n <td class=\"content-container\">\n \n <em>ID</em>: AA76FF0E-0EF9-40E6-9913-90FA63D50298\n <br/>\n \n \n <em>Description</em>:\n <p style=\"white-space: pre-line\" class=\"tab-one\">None</p>\n \n \n \n \n <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator-exclusions\">Denominator Exclusions</a> \n \n \n </td>\n </tr>\n \n\n \n <tr>\n \n \n<th scope=\"row\" class=\"row-header\">Numerator</th>\n\n \n <td class=\"content-container\">\n \n <em>ID</em>: 3D2BED97-5ADC-4210-8A3E-91B13652E7D0\n <br/>\n \n \n <em>Description</em>:\n <p style=\"white-space: pre-line\" class=\"tab-one\">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.</p>\n \n \n \n \n <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-numerator\">Numerator</a> \n \n \n </td>\n </tr>\n \n\n \n <tr>\n \n \n<th scope=\"row\" class=\"row-header\">Denominator Exception</th>\n\n \n <td class=\"content-container\">\n \n <em>ID</em>: 4511743B-B054-4A08-800B-C4624450C38C\n <br/>\n \n \n <em>Description</em>:\n <p style=\"white-space: pre-line\" class=\"tab-one\">None</p>\n \n \n \n \n <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator-exceptions\">Denominator Exceptions</a> \n \n \n </td>\n </tr>\n \n\n \n \n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Population Basis</th>\n\n<td class=\"content-container\">Patient</td>\n</tr>\n\n\n\n\n\n\n\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Type</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-type process}\">Process</span></td>\n</tr>\n\n\n\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Rate Aggregation</th>\n\n<td class=\"content-container\">None</td>\n</tr>\n\n\n\n \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Improvement Notation</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-improvement-notation increase}\">Increased score indicates improvement</span></td>\n</tr>\n\n\n\n\n\n\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Logic</th>\n\n</tr>\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Primary Library</th>\n\n<td class=\"content-container\"><a href=\"Library-GoalFollowUpMeasure.html\">GoalFollowUpMeasure</a></td>\n</tr>\n\n\n\n\n \n \n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Library PCOLogic\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0</code>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Library FHIRHelpers\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000</code>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Library PC\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0</code>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Code system LOINC\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"http://terminology.hl7.org/5.2.0/CodeSystem-v3-loinc.html\">Logical Observation Identifiers, Names and Codes (LOINC)</a>\n <br/>\n <em>Canonical URL</em>: <tt>http://loinc.org</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Value set PCO Categories\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset</code>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Value set Goal Attainment Scaling (GAS) Score\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score</tt>\n \n </td>\n</tr>\n\n<tr>\n \n \n \n \n \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n \n <td class=\"content-container\">\n \n <em>Description</em>: Value set PROM Target Measures\n \n <br/>\n \n \n \n \n \n \n <em>Resource</em>: <a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a>\n <br/>\n <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures</tt>\n \n </td>\n</tr>\n\n\n \n <tr>\n <th scope=\"row\" class=\"row-header\">Direct Reference Code</th>\n <td class=\"content-container\">\n \n <em>Display</em>: Goal attainment scale\n <br/>\n \n <em>Code</em>: 68489\n <br/>\n <em>System</em>: <tt>http://loinc.org</tt>\n </td>\n </tr>\n\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Measurement Period\n <br/>\n <em>Use</em>: In\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: 1\n <br/>\n <em>Type</em>: Period\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Follow-Up Interval\n <br/>\n <em>Use</em>: In\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: 1\n <br/>\n <em>Type</em>: Range\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Numerator\n <br/>\n <em>Use</em>: Out\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: *\n <br/>\n <em>Type</em>: Patient\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Denominator\n <br/>\n <em>Use</em>: Out\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: *\n <br/>\n <em>Type</em>: Patient\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Initial Population\n <br/>\n <em>Use</em>: Out\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: *\n <br/>\n <em>Type</em>: Patient\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Denominator Exclusions\n <br/>\n <em>Use</em>: Out\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: 1\n <br/>\n <em>Type</em>: Resource\n </td>\n</tr>\n \n <tr>\n \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n <td class=\"content-container\">\n <em>Name</em>: Denominator Exceptions\n <br/>\n <em>Use</em>: Out\n <br/>\n <em>Min Cardinality</em>: 0\n <br/>\n <em>Max Cardinality</em>: 1\n <br/>\n <em>Type</em>: Resource\n </td>\n</tr>\n \n \n <tr>\n <th colspan=\"2\" scope=\"row\" class=\"section-header\"><a name=\"effective-data-requirements\"> </a>Measure Logic Data Requirements</th>\n </tr>\n \n \n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: Patient\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/R4/patient.html\">Patient</a>\n <br/> \n \n \n \n \n </td>\n</tr>\n\n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: Goal\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/R4/goal.html\">Goal</a>\n <br/> \n \n \n \n <em>Must Support Elements</em>: category, start, measure, id\n <br/>\n \n \n </td>\n</tr>\n\n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: Observation\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>\n <br/> \n \n \n \n <em>Must Support Elements</em>: code\n <br/>\n \n \n <em>Code Filter(s)</em>: \n <br/>\n \n \n <span class=\"tab-one\"><em>Path</em>: code</span>\n <br/>\n \n \n \n <span class=\"tab-one\"><em>ValueSet</em>:</span> <a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a>\n <br/> \n \n \n \n \n </td>\n</tr>\n\n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: Observation\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>\n <br/> \n \n \n \n <em>Must Support Elements</em>: code\n <br/>\n \n \n <em>Code Filter(s)</em>: \n <br/>\n \n \n <span class=\"tab-one\"><em>Path</em>: code</span>\n <br/>\n \n \n \n <span class=\"tab-one\"><em>ValueSet</em>:</span> <a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a>\n <br/> \n \n \n \n \n </td>\n</tr>\n\n<tr>\n <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n <td class=\"content-container\">\n <em>Type</em>: CarePlan\n <br/>\n \n <em>Profile(s)</em>: \n \n <a href=\"http://hl7.org/fhir/R4/careplan.html\">CarePlan</a>\n <br/> \n \n \n \n <em>Must Support Elements</em>: goal\n <br/>\n \n \n </td>\n</tr>\n\n \n <tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Logic Definitions</th>\n\n</tr>\n \n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalfollowupmeasure-initial-population\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Includes individuals 18 years of age and older.\n*/\ndefine "Initial Population": {\n Patient person\n where AgeInYearsAt(start of "Measurement Period") >= 18\n}</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalfollowupmeasure-denominator\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Initial Population individuals with a complex care need and has a PCO Goal.\n@comment: TODO - How do we determine "complex care need?"\n*/\ndefine "Denominator":\n "Initial Population"</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-pco-goals\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/* \n A "PCO Goal" is any FHIR Goal that has a category in "PCO Categories"\n and has a start date.\n TODO: or a Goal that addresses a What Matters observation.\n*/\ndefine "PCO Goals":\n [Goal] goal\n where goal.category in "PCO Categories"\n and (goal.start as FHIR.date) is not null</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-gas-scores\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Observations containing a GAS score.\ndefine "GAS Scores":\n [Observation: "Goal Attainment Scaling (GAS) Score"]</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-pco-goals-during-measurement-period\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// PCO Goals whose startDate falls within the Measurement Period\ndefine "PCO Goals During Measurement Period":\n "PCO Goals" goal\n where (ToDateTime(goal.start as FHIR.date) during "Measurement Period")\n and (goal.hasGAS() or goal.hasPROM())\n and exists goal.carePlans()</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-prom-scores\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Observations containing a PROM score.\ndefine "PROM Scores":\n [Observation: "PROM Target Measures"]</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-follow-up-scores-during-measurement-period\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/* \nFollow-Up Scares are PCO score observations taken during the Measurement Period,\nand during the follow-up period for its Goal. Default follow-up period is \n2 weeks to 6 months following the goal startDate.\n*/\ndefine "Follow-Up Scores During Measurement Period":\n flatten( "PCO Goals During Measurement Period" goal\n let pcoScores: goal.pcoScores()\n return pcoScores score \n let scoreDate: score.effective as FHIR.dateTime\n where scoreDate during "Measurement Period"\n and scoreDate during "Follow-Up Interval For"(goal)\n )</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalfollowupmeasure-numerator\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Indivuals who received follow-up on their PCO goal within two\nweeks to six months of when the PCO goal and GAS or PROM were identified.\n*/\ndefine "Numerator":\n "Denominator" person\n where exists PCOLogic."Follow-Up Scores During Measurement Period"</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalfollowupmeasure-denominator-exclusions\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define "Denominator Exclusions":\n null</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalfollowupmeasure-denominator-exceptions\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define "Denominator Exceptions":\n null</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"fhirhelpers-toconcept\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n if concept is null then\n null\n else\n System.Concept {\n codes: concept.coding C return ToCode(C),\n display: concept.text.value\n }</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"fhirhelpers-todate\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToDate(value date): value.value</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-hasgas\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// where exists obs.performer.resolveRelatedPersons()\n\ndefine fluent function hasGAS(goal Goal):\n exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling')\n or exists (goal.target target\n where target.measure = "Goal attainment scale"\n )\n or exists goal.gasScores()</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"pcocommon-extensions\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Returns any extensions defined on the given resource with the specified url.\n@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access\ncontent that is defined by extensions but not yet surfaced in the\nCQL model info.\n*/\ndefine fluent function extensions(domainResource DomainResource, url String):\n domainResource.extension E\n\t where E.url = url\n\t\treturn E</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"fhirhelpers-tostring\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToString(value uri): value.value</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-gasscores\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including only GAS scores\ndefine fluent function gasScores(goal Goal):\n "GAS Scores" score\n where score.focusGoals() contains goal</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-focusgoals\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Goal where focus includes the given Observation.\ndefine fluent function focusGoals(obs Observation):\n obs.focus.resolveGoals()</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"pcocommon-resolvegoals\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define fluent function resolveGoals(references List<Reference>):\n flatten( references ref\n return [Goal] resource\n where resource.id = ref.reference.getId()\n )</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"pcocommon-getid\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define fluent function getId(uri String):\n Last(Split(uri, '/'))</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-hasprom\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/// Returns true if this Goal has a PROM code in its target.measure\ndefine fluent function hasPROM(goal Goal):\n exists (goal.target target\n where target.measure in "PROM Target Measures"\n )</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"pcocommon-careplans\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of CarePlan that support this Goal.\ndefine fluent function carePlans(goal Goal):\n [CarePlan] carePlan\n where exists ( carePlan.goal goalRef\n where goal.id = goalRef.reference.getId()\n )</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-pcoscores\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including both GAS and PROM scores\ndefine fluent function pcoScores(goal Goal):\n goal.gasScores()\n union goal.promScores()</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-promscores\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including only PROM scores\ndefine fluent function promScores(goal Goal):\n "PROM Scores" score\n where score.focusGoals() contains goal</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"fhirhelpers-todatetime\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToDateTime(value dateTime): value.value</code></pre>\n </td>\n\n</tr>\n \n<tr>\n <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n \n \n <a name=\"goalattainmentlogic-follow-up-interval-for\"> </a>\n \n Logic Definition\n </th>\n\n <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n <td>\n <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\nComputes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter.\n@return Interval<DateTime>\n*/\ndefine function "Follow-Up Interval For" (goal Goal):\n goal goal\n let startDate: ToDateTime(goal.start as FHIR.date)\n return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval")</code></pre>\n </td>\n\n</tr>\n\n \n\n<tr>\n <th colspan=\"2\" scope=\"row\" class=\"row-header\">Generated using version 0.4.6 of the sample-content-ig Liquid templates</th>\n</tr>\n </tbody>\n </table>\n</div>"
},
"contained" : [
{
"resourceType" : "Library",
"id" : "effective-data-requirements",
"extension" : [
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
"valueCoding" : {
"system" : "http://loinc.org",
"code" : "68489",
"display" : "Goal attainment scale"
}
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalFollowUpMeasure"
},
{
"url" : "name",
"valueString" : "Initial Population"
},
{
"url" : "statement",
"valueString" : "/*\n@description: Includes individuals 18 years of age and older.\n*/\ndefine \"Initial Population\": {\n Patient person\n where AgeInYearsAt(start of \"Measurement Period\") >= 18\n}"
},
{
"url" : "displaySequence",
"valueInteger" : 0
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalFollowUpMeasure"
},
{
"url" : "name",
"valueString" : "Denominator"
},
{
"url" : "statement",
"valueString" : "/*\n@description: Initial Population individuals with a complex care need and has a PCO Goal.\n@comment: TODO - How do we determine \"complex care need?\"\n*/\ndefine \"Denominator\":\n \"Initial Population\""
},
{
"url" : "displaySequence",
"valueInteger" : 1
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "PCO Goals"
},
{
"url" : "statement",
"valueString" : "/* \n A \"PCO Goal\" is any FHIR Goal that has a category in \"PCO Categories\"\n and has a start date.\n TODO: or a Goal that addresses a What Matters observation.\n*/\ndefine \"PCO Goals\":\n [Goal] goal\n where goal.category in \"PCO Categories\"\n and (goal.start as FHIR.date) is not null"
},
{
"url" : "displaySequence",
"valueInteger" : 2
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "GAS Scores"
},
{
"url" : "statement",
"valueString" : "// Observations containing a GAS score.\ndefine \"GAS Scores\":\n [Observation: \"Goal Attainment Scaling (GAS) Score\"]"
},
{
"url" : "displaySequence",
"valueInteger" : 3
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "PCO Goals During Measurement Period"
},
{
"url" : "statement",
"valueString" : "// PCO Goals whose startDate falls within the Measurement Period\ndefine \"PCO Goals During Measurement Period\":\n \"PCO Goals\" goal\n where (ToDateTime(goal.start as FHIR.date) during \"Measurement Period\")\n and (goal.hasGAS() or goal.hasPROM())\n and exists goal.carePlans()"
},
{
"url" : "displaySequence",
"valueInteger" : 4
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],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "PROM Scores"
},
{
"url" : "statement",
"valueString" : "// Observations containing a PROM score.\ndefine \"PROM Scores\":\n [Observation: \"PROM Target Measures\"]"
},
{
"url" : "displaySequence",
"valueInteger" : 5
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "Follow-Up Scores During Measurement Period"
},
{
"url" : "statement",
"valueString" : "/* \nFollow-Up Scares are PCO score observations taken during the Measurement Period,\nand during the follow-up period for its Goal. Default follow-up period is \n2 weeks to 6 months following the goal startDate.\n*/\ndefine \"Follow-Up Scores During Measurement Period\":\n flatten( \"PCO Goals During Measurement Period\" goal\n let pcoScores: goal.pcoScores()\n return pcoScores score \n let scoreDate: score.effective as FHIR.dateTime\n where scoreDate during \"Measurement Period\"\n and scoreDate during \"Follow-Up Interval For\"(goal)\n )"
},
{
"url" : "displaySequence",
"valueInteger" : 6
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],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalFollowUpMeasure"
},
{
"url" : "name",
"valueString" : "Numerator"
},
{
"url" : "statement",
"valueString" : "/*\n@description: Indivuals who received follow-up on their PCO goal within two\nweeks to six months of when the PCO goal and GAS or PROM were identified.\n*/\ndefine \"Numerator\":\n \"Denominator\" person\n where exists PCOLogic.\"Follow-Up Scores During Measurement Period\""
},
{
"url" : "displaySequence",
"valueInteger" : 7
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalFollowUpMeasure"
},
{
"url" : "name",
"valueString" : "Denominator Exclusions"
},
{
"url" : "statement",
"valueString" : "define \"Denominator Exclusions\":\n null"
},
{
"url" : "displaySequence",
"valueInteger" : 8
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalFollowUpMeasure"
},
{
"url" : "name",
"valueString" : "Denominator Exceptions"
},
{
"url" : "statement",
"valueString" : "define \"Denominator Exceptions\":\n null"
},
{
"url" : "displaySequence",
"valueInteger" : 9
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "FHIRHelpers"
},
{
"url" : "name",
"valueString" : "ToConcept"
},
{
"url" : "statement",
"valueString" : "/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n if concept is null then\n null\n else\n System.Concept {\n codes: concept.coding C return ToCode(C),\n display: concept.text.value\n }"
},
{
"url" : "displaySequence",
"valueInteger" : 10
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "FHIRHelpers"
},
{
"url" : "name",
"valueString" : "ToDate"
},
{
"url" : "statement",
"valueString" : "define function ToDate(value date): value.value"
},
{
"url" : "displaySequence",
"valueInteger" : 11
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "hasGAS"
},
{
"url" : "statement",
"valueString" : "// where exists obs.performer.resolveRelatedPersons()\n\ndefine fluent function hasGAS(goal Goal):\n exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling')\n or exists (goal.target target\n where target.measure = \"Goal attainment scale\"\n )\n or exists goal.gasScores()"
},
{
"url" : "displaySequence",
"valueInteger" : 12
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "PCOCommon"
},
{
"url" : "name",
"valueString" : "extensions"
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{
"url" : "statement",
"valueString" : "/*\n@description: Returns any extensions defined on the given resource with the specified url.\n@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access\ncontent that is defined by extensions but not yet surfaced in the\nCQL model info.\n*/\ndefine fluent function extensions(domainResource DomainResource, url String):\n domainResource.extension E\n\t where E.url = url\n\t\treturn E"
},
{
"url" : "displaySequence",
"valueInteger" : 13
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "FHIRHelpers"
},
{
"url" : "name",
"valueString" : "ToString"
},
{
"url" : "statement",
"valueString" : "define function ToString(value uri): value.value"
},
{
"url" : "displaySequence",
"valueInteger" : 14
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "gasScores"
},
{
"url" : "statement",
"valueString" : "// Returns a list of Observation including only GAS scores\ndefine fluent function gasScores(goal Goal):\n \"GAS Scores\" score\n where score.focusGoals() contains goal"
},
{
"url" : "displaySequence",
"valueInteger" : 15
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "focusGoals"
},
{
"url" : "statement",
"valueString" : "// Returns a list of Goal where focus includes the given Observation.\ndefine fluent function focusGoals(obs Observation):\n obs.focus.resolveGoals()"
},
{
"url" : "displaySequence",
"valueInteger" : 16
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "PCOCommon"
},
{
"url" : "name",
"valueString" : "resolveGoals"
},
{
"url" : "statement",
"valueString" : "define fluent function resolveGoals(references List<Reference>):\n flatten( references ref\n return [Goal] resource\n where resource.id = ref.reference.getId()\n )"
},
{
"url" : "displaySequence",
"valueInteger" : 17
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "PCOCommon"
},
{
"url" : "name",
"valueString" : "getId"
},
{
"url" : "statement",
"valueString" : "define fluent function getId(uri String):\n Last(Split(uri, '/'))"
},
{
"url" : "displaySequence",
"valueInteger" : 18
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "hasPROM"
},
{
"url" : "statement",
"valueString" : "/// Returns true if this Goal has a PROM code in its target.measure\ndefine fluent function hasPROM(goal Goal):\n exists (goal.target target\n where target.measure in \"PROM Target Measures\"\n )"
},
{
"url" : "displaySequence",
"valueInteger" : 19
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "PCOCommon"
},
{
"url" : "name",
"valueString" : "carePlans"
},
{
"url" : "statement",
"valueString" : "// Returns a list of CarePlan that support this Goal.\ndefine fluent function carePlans(goal Goal):\n [CarePlan] carePlan\n where exists ( carePlan.goal goalRef\n where goal.id = goalRef.reference.getId()\n )"
},
{
"url" : "displaySequence",
"valueInteger" : 20
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "pcoScores"
},
{
"url" : "statement",
"valueString" : "// Returns a list of Observation including both GAS and PROM scores\ndefine fluent function pcoScores(goal Goal):\n goal.gasScores()\n union goal.promScores()"
},
{
"url" : "displaySequence",
"valueInteger" : 21
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "promScores"
},
{
"url" : "statement",
"valueString" : "// Returns a list of Observation including only PROM scores\ndefine fluent function promScores(goal Goal):\n \"PROM Scores\" score\n where score.focusGoals() contains goal"
},
{
"url" : "displaySequence",
"valueInteger" : 22
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "FHIRHelpers"
},
{
"url" : "name",
"valueString" : "ToDateTime"
},
{
"url" : "statement",
"valueString" : "define function ToDateTime(value dateTime): value.value"
},
{
"url" : "displaySequence",
"valueInteger" : 23
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "GoalAttainmentLogic"
},
{
"url" : "name",
"valueString" : "Follow-Up Interval For"
},
{
"url" : "statement",
"valueString" : "/*\nComputes the follow-up interval for a Goal based on this measure's \"Follow-Up Interval\" parameter.\n@return Interval<DateTime>\n*/\ndefine function \"Follow-Up Interval For\" (goal Goal):\n goal goal\n let startDate: ToDateTime(goal.start as FHIR.date)\n return Interval(startDate + start of \"Follow-Up Interval\", startDate + end of \"Follow-Up Interval\")"
},
{
"url" : "displaySequence",
"valueInteger" : 24
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
}
],
"name" : "EffectiveDataRequirements",
"status" : "active",
"type" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/library-type",
"code" : "module-definition"
}
]
},
"relatedArtifact" : [
{
"type" : "depends-on",
"display" : "Library PCOLogic",
"resource" : "http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0"
},
{
"type" : "depends-on",
"display" : "Library FHIRHelpers",
"resource" : "http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000"
},
{
"type" : "depends-on",
"display" : "Library PC",
"resource" : "http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0"
},
{
"type" : "depends-on",
"display" : "Code system LOINC",
"resource" : "http://loinc.org"
},
{
"type" : "depends-on",
"display" : "Value set PCO Categories",
"resource" : "http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset"
},
{
"type" : "depends-on",
"display" : "Value set Goal Attainment Scaling (GAS) Score",
"resource" : "http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score"
},
{
"type" : "depends-on",
"display" : "Value set PROM Target Measures",
"resource" : "http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures"
}
],
"parameter" : [
{
"name" : "Measurement Period",
"use" : "in",
"min" : 0,
"max" : "1",
"type" : "Period"
},
{
"name" : "Follow-Up Interval",
"use" : "in",
"min" : 0,
"max" : "1",
"type" : "Range"
},
{
"name" : "Numerator",
"use" : "out",
"min" : 0,
"max" : "*",
"type" : "Patient"
},
{
"name" : "Denominator",
"use" : "out",
"min" : 0,
"max" : "*",
"type" : "Patient"
},
{
"name" : "Initial Population",
"use" : "out",
"min" : 0,
"max" : "*",
"type" : "Patient"
},
{
"name" : "Denominator Exclusions",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "Resource"
},
{
"name" : "Denominator Exceptions",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "Resource"
}
],
"dataRequirement" : [
{
"type" : "Patient",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Patient"
]
},
{
"type" : "Goal",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Goal"
],
"mustSupport" : [
"category",
"start",
"measure",
"id"
]
},
{
"type" : "Observation",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Observation"
],
"mustSupport" : [
"code"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score"
}
]
},
{
"type" : "Observation",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Observation"
],
"mustSupport" : [
"code"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures"
}
]
},
{
"type" : "CarePlan",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/CarePlan"
],
"mustSupport" : [
"goal"
]
}
]
}
],
"extension" : [
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem",
"valueReference" : {
🔗 "reference" : "Device/cqf-tooling"
}
},
{
"id" : "effective-data-requirements",
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements",
"valueReference" : {
"reference" : "#effective-data-requirements"
}
}
],
"url" : "http://hl7.org/fhir/us/pco/Measure/GoalFollowUpMeasure",
"identifier" : [
{
"use" : "usual",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "short-name"
}
]
},
"system" : "https://madie.cms.gov/measure/shortName",
"value" : "PCOMeasure1"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "version-independent"
}
]
},
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "version-specific"
}
]
},
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "publisher"
}
]
},
"system" : "https://madie.cms.gov/measure/cmsId",
"value" : "NA",
"assigner" : {
"display" : "CMS"
}
}
],
"version" : "0.2.0",
"name" : "GoalFollowUpMeasure",
"title" : "Person-Centered Goal Follow-Up",
"status" : "active",
"experimental" : false,
"date" : "2024-12-11T00:23:37+00:00",
"publisher" : "HL7 International / Patient Care",
"contact" : [
{
"name" : "HL7 International / Patient Care",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/patientcare"
},
{
"system" : "email",
"value" : "patientcare@lists.HL7.org"
}
]
}
],
"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.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"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.",
"usage" : "Content TBD.",
"copyright" : "Measure definition is copyright 2024 by NCQA.\n\nLOINC(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.",
"effectivePeriod" : {
"start" : "2024-01-01",
"end" : "2024-12-31"
},
"author" : [
{
"name" : "HL7 International / Patient Care",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/patientcare"
}
]
}
],
"library" : [
🔗 "http://hl7.org/fhir/us/pco/Library/GoalFollowUpMeasure"
],
"disclaimer" : "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.",
"scoring" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-scoring",
"code" : "proportion",
"display" : "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.",
"clinicalRecommendationStatement" : "None at this time.",
"group" : [
{
"id" : "64f0d91d56d636294b157d97",
"extension" : [
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
"valueCode" : "Patient"
},
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-type",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-type",
"code" : "process",
"display" : "Process"
}
]
}
},
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-rateAggregation",
"valueString" : "None"
},
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-improvementNotation",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
"code" : "increase",
"display" : "Increased score indicates improvement"
}
]
}
}
],
"description" : "Content TBD",
"population" : [
{
"id" : "692C6F6B-4153-496F-8582-0839A0816567",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "initial-population",
"display" : "Initial Population"
}
]
},
"description" : "Individuals 18 years of age and older.",
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Initial Population"
}
},
{
"id" : "3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator",
"display" : "Denominator"
}
]
},
"description" : "Individuals 18 years of age and older with a complex care need and has a PCO Goal.",
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator"
}
},
{
"id" : "AA76FF0E-0EF9-40E6-9913-90FA63D50298",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator-exclusion",
"display" : "Denominator Exclusion"
}
]
},
"description" : "None",
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator Exclusions"
}
},
{
"id" : "3D2BED97-5ADC-4210-8A3E-91B13652E7D0",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "numerator",
"display" : "Numerator"
}
]
},
"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.",
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Numerator"
}
},
{
"id" : "4511743B-B054-4A08-800B-C4624450C38C",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator-exception",
"display" : "Denominator Exception"
}
]
},
"description" : "None",
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator Exceptions"
}
}
]
}
]
}
IG © 2024+ HL7 International / Patient Care. Package hl7.fhir.us.pco#0.2.0 based on FHIR 4.0.1. Generated 2024-12-13
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