Person-Centered Outcomes
0.2.0 - ci-build
Person-Centered Outcomes
0.2.0 - ci-build
Person-Centered Outcomes, published by Mountain Lotus WellBeing LLC. 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 2024-09-22 |
{
"resourceType" : "Measure",
"id" : "GoalFollowUpMeasure",
"meta" : {
"profile" : [
🔗 "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=\"grid dict\">\n \n <tr>\n <th scope=\"row\"><b>Title: </b></th>\n <td style=\"padding-left: 4px;\">Person-Centered Goal Follow-Up</td>\n </tr>\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Id: </b></th>\n <td style=\"padding-left: 4px;\">GoalFollowUpMeasure</td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Version: </b></th>\n <td style=\"padding-left: 4px;\">0.2.0</td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Url: </b></th>\n <td style=\"padding-left: 4px;\"><a href=\"Measure-GoalFollowUpMeasure.html\">Person-Centered Goal Follow-Up</a></td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\">\n <b>\n \n \n short-name identifier:\n \n \n </b>\n </th>\n\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <span>PCOMeasure1</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\">\n <b>\n \n \n version-independent identifier:\n \n \n </b>\n </th>\n\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <span>urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\">\n <b>\n \n \n version-specific identifier:\n \n \n </b>\n </th>\n\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <span>urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\">\n <b>\n \n \n publisher (CMS) identifier:\n \n \n </b>\n </th>\n\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <span>NA</span>\n </p>\n \n </td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Effective Period: </b></th>\n <td style=\"padding-left: 4px;\">2024-01-01..2024-12-31</td>\n </tr>\n \n\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Publisher: </b></th>\n <td style=\"padding-left: 4px;\">Mountain Lotus WellBeing LLC</td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Author: </b></th>\n <td style=\"padding-left: 4px;\">Mountain Lotus WellBeing LLC</td>\n </tr>\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Description: </b></th>\n <td style=\"padding-left: 4px;\"><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 \n\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Jurisdiction: </b></th>\n <td style=\"padding-left: 4px;\">001</td>\n </tr>\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Purpose: </b></th>\n <td style=\"padding-left: 4px;\"><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 \n <tr>\n <th scope=\"row\"><b>Copyright: </b></th>\n <td style=\"padding-left: 4px;\"><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 <tr>\n <th scope=\"row\"><b>Disclaimer: </b></th>\n <td style=\"padding-left: 4px;\"><div><p>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.</p>\n</div></td>\n </tr>\n \n\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Scoring: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n <p style=\"margin-bottom: 5px;\">\n <span>Proportion </span>\n </p>\n \n \n \n </td>\n </tr>\n \n\n \n\n \n\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Rationale: </b></th>\n <td style=\"padding-left: 4px;\"><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 \n <tr>\n <th scope=\"row\"><b>Clinical recommendation statement: </b></th>\n <td style=\"padding-left: 4px;\"><div><p>None at this time.</p>\n</div></td>\n </tr>\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Guidance (Usage): </b></th>\n <td style=\"padding-left: 4px;\">Content TBD.</td>\n </tr>\n \n\n \n \n <tr>\n <th scope=\"row\"><b>Population Criteria: </b></th>\n <td style=\"padding-left: 4px;\">\n \n <table class=\"grid-dict\">\n \n <tr>\n <th><b>64f0d91d56d636294b157d97</b></th>\n </tr>\n \n \n <tr>\n <td>Initial Population:</td>\n\n \n \n <td>Individuals 18 years of age and older.</td>\n \n \n\n </tr>\n \n <tr>\n <td>Denominator:</td>\n\n \n \n <td>Individuals 18 years of age and older with a complex care need and has a PCO Goal.</td>\n \n \n\n </tr>\n \n <tr>\n <td>Denominator Exclusion:</td>\n\n \n \n <td>None</td>\n \n \n\n </tr>\n \n <tr>\n <td>Numerator:</td>\n\n \n \n <td>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.</td>\n \n \n\n </tr>\n \n <tr>\n <td>Denominator Exception:</td>\n\n \n \n <td>None</td>\n \n \n\n </tr>\n \n \n </table>\n \n </td>\n </tr>\n \n \n\n \n\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Libraries: </b></th>\n <td style=\"padding-left: 4px;\">\n <table class=\"grid-dict\">\n \n <tr>\n <td><a href=\"Library-GoalFollowUpMeasure.html\">GoalFollowUpMeasure</a></td>\n </tr>\n \n </table>\n </td>\n </tr>\n \n\n \n\n \n \n <tr>\n <th scope=\"row\"><b>Terminology and Other Dependencies: </b></th>\n <td style=\"padding-left: 4px;\">\n \n <li><code>http://mtnlotus.com/uv/pco/Library/GoalAttainmentLogic|0.1.0</code></li>\n \n <li><code>http://mtnlotus.com/uv/pco/Library/FHIRHelpers|4.4.000</code></li>\n \n <li><code>http://mtnlotus.com/uv/pco/Library/PCOCommon|0.1.0</code></li>\n \n <li><a href=\"http://terminology.hl7.org/5.2.0/CodeSystem-v3-loinc.html\">Logical Observation Identifiers, Names and Codes (LOINC)</a></li>\n \n <li><a href=\"ValueSet-pco-category-valueset.html\">PCO Categories</a></li>\n \n <li><a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a></li>\n \n <li><a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a></li>\n \n </td>\n </tr>\n <tr>\n <th scope=\"row\"><b>Parameters:</b></th>\n <td style=\"padding-left: 4px;\">\n <table class=\"grid-dict\">\n <tr>\n <th><b>name</b></th>\n <th><b>use</b></th>\n <th><b>min</b></th>\n <th><b>max</b></th>\n <th><b>type</b></th>\n </tr>\n \n <tr>\n <td>Measurement Period</td>\n <td>In</td>\n <td>0</td>\n <td>1</td>\n <td>Period</td>\n </tr>\n \n <tr>\n <td>Follow-Up Interval</td>\n <td>In</td>\n <td>0</td>\n <td>1</td>\n <td>Range</td>\n </tr>\n \n <tr>\n <td>Numerator</td>\n <td>Out</td>\n <td>0</td>\n <td>*</td>\n <td>Patient</td>\n </tr>\n \n <tr>\n <td>Denominator</td>\n <td>Out</td>\n <td>0</td>\n <td>*</td>\n <td>Patient</td>\n </tr>\n \n <tr>\n <td>Initial Population</td>\n <td>Out</td>\n <td>0</td>\n <td>*</td>\n <td>Patient</td>\n </tr>\n \n <tr>\n <td>Denominator Exclusions</td>\n <td>Out</td>\n <td>0</td>\n <td>1</td>\n <td>Resource</td>\n </tr>\n \n <tr>\n <td>Denominator Exceptions</td>\n <td>Out</td>\n <td>0</td>\n <td>1</td>\n <td>Resource</td>\n </tr>\n \n </table>\n </td>\n </tr>\n\n <tr>\n <th scope=\"row\"><b>DataRequirements:</b></th>\n <td style=\"padding-left: 4px;\">\n <table class=\"grid-dict\">\n <tr>\n <th><b>Resource Type</b></th>\n <th><b>Resource Elements</b></th>\n <th><b>Valueset Name</b></th>\n <th><b>Valueset</b></th>\n </tr>\n \n <tr>\n <td>Patient(<a href=\"http://hl7.org/fhir/R4/patient.html\">Patient</a>)</td>\n <td>\n \n </td>\n <td>\n \n </td>\n <td/>\n </tr>\n \n <tr>\n <td>Goal(<a href=\"http://hl7.org/fhir/R4/goal.html\">Goal</a>)</td>\n <td>\n \n category\n \n start\n \n measure\n \n id\n \n </td>\n <td>\n \n </td>\n <td/>\n </tr>\n \n <tr>\n <td>Observation(<a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>)</td>\n <td>\n \n code\n \n </td>\n <td>\n \n \n Goal Attainment Scaling (GAS) Score\n \n \n </td>\n <td><a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a></td>\n </tr>\n \n <tr>\n <td>Observation(<a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>)</td>\n <td>\n \n code\n \n </td>\n <td>\n \n \n PROM Target Measures\n \n \n </td>\n <td><a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a></td>\n </tr>\n \n <tr>\n <td>CarePlan(<a href=\"http://hl7.org/fhir/R4/careplan.html\">CarePlan</a>)</td>\n <td>\n \n goal\n \n </td>\n <td>\n \n </td>\n <td/>\n </tr>\n \n </table>\n </td>\n </tr>\n\n \n <tr>\n <th scope=\"row\"><b>Direct Reference Codes:</b></th>\n <td style=\"padding-left: 4px;\">\n <table class=\"grid-dict\">\n <tr>\n <th><b>display</b></th>\n <th><b>code</b></th>\n <th><b>system</b></th>\n </tr>\n \n <tr>\n <td>Goal attainment scale</td>\n <td>68489</td>\n <td><a href=\"http://terminology.hl7.org/6.0.2/CodeSystem-v3-loinc.html\">http://loinc.org</a></td>\n </tr>\n \n </table>\n </td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Logic Definitions:</b></th>\n <td style=\"padding-left: 4px;\">\n \n <table class=\"grid-dict\">\n <tr>\n <th><b>Group</b></th>\n <th><b>Scoring</b></th>\n <th><b>Population Criteria</b></th>\n <th><b>Expression</b></th>\n </tr>\n <tr>\n \n <td> 64f0d91d56d636294b157d97 </td>\n <td colspan=\"3\" style=\"padding-left: 4px;\">\n \n\n \n\n \n <b>Measure scoring:</b>\n \n <p style=\"margin-bottom: 5px;\">\n <span>Proportion</span>\n </p>\n \n \n\n \n\n \n <tr>\n \n <th scope=\"row\"><b>Type: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n <p style=\"margin-bottom: 5px;\">\n <span>Process </span>\n </p>\n \n \n \n </td>\n \n </tr>\n \n\n \n\n \n <tr>\n <th scope=\"row\"><b>Rate Aggregation: </b></th>\n <td colspan=\"3\" style=\"padding-left: 4px;\">None</td>\n </tr>\n \n\n \n <tr>\n <th scope=\"row\"><b>Improvement Notation: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n \n <p style=\"margin-bottom: 5px;\">\n <span>Increased score indicates improvement </span>\n </p>\n \n \n \n \n </td>\n </tr>\n \n\n \n\n </td>\n \n <tr>\n <td/>\n <td/>\n <td>Initial Population</td>\n <td>\n \n <pre><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 \n </td>\n </tr>\n \n <tr>\n <td/>\n <td/>\n <td>Denominator</td>\n <td>\n \n <pre><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 \n </td>\n </tr>\n \n <tr>\n <td/>\n <td/>\n <td>Denominator Exclusion</td>\n <td>\n \n <pre><code class=\"language-cql\">define "Denominator Exclusions":\n null</code></pre>\n \n </td>\n </tr>\n \n <tr>\n <td/>\n <td/>\n <td>Numerator</td>\n <td>\n \n <pre><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 \n </td>\n </tr>\n \n <tr>\n <td/>\n <td/>\n <td>Denominator Exception</td>\n <td>\n \n <pre><code class=\"language-cql\">define "Denominator Exceptions":\n null</code></pre>\n \n </td>\n </tr>\n \n \n \n </tr>\n </table>\n \n\n <table class=\"grid-dict\">\n \n <tr>\n <th><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalFollowUpMeasure</td>\n \n \n <td>Initial Population</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalFollowUpMeasure</td>\n \n \n <td>Denominator</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>PCO Goals</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>GAS Scores</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>PCO Goals During Measurement Period</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>PROM Scores</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>Follow-Up Scores During Measurement Period</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalFollowUpMeasure</td>\n \n \n <td>Numerator</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalFollowUpMeasure</td>\n \n \n <td>Denominator Exclusions</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"highlight language-cql\"><code class=\"language-cql\">define "Denominator Exclusions":\n null</code></pre>\n </td>\n \n </tr>\n \n <tr>\n <th><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalFollowUpMeasure</td>\n \n \n <td>Denominator Exceptions</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"highlight language-cql\"><code class=\"language-cql\">define "Denominator Exceptions":\n null</code></pre>\n </td>\n \n </tr>\n \n <tr>\n <th><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>FHIRHelpers</td>\n \n \n <td>ToConcept</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>FHIRHelpers</td>\n \n \n <td>ToDate</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>hasGAS</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"highlight language-cql\"><code class=\"language-cql\">// where exists obs.performer.resolveRelatedPersons()\n\ndefine fluent function hasGAS(goal Goal):\n exists goal.extensions('http://mtnlotus.com/uv/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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>PCOCommon</td>\n \n \n <td>extensions</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>FHIRHelpers</td>\n \n \n <td>ToString</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>gasScores</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>focusGoals</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>PCOCommon</td>\n \n \n <td>resolveGoals</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>PCOCommon</td>\n \n \n <td>getId</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>hasPROM</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>PCOCommon</td>\n \n \n <td>carePlans</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>pcoScores</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>promScores</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>FHIRHelpers</td>\n \n \n <td>ToDateTime</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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><b>Library Name</b></th>\n <th><b>Name</b></th>\n </tr>\n <tr>\n \n <td>GoalAttainmentLogic</td>\n \n \n <td>Follow-Up Interval For</td>\n \n </tr>\n <tr>\n \n <td/>\n <td>\n <pre class=\"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 </table>\n </td>\n </tr>\n \n \n \n\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
}
],
"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
}
],
"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://mtnlotus.com/uv/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"
},
{
"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://mtnlotus.com/uv/pco/Library/GoalAttainmentLogic|0.1.0"
},
{
"type" : "depends-on",
"display" : "Library FHIRHelpers",
"resource" : "http://mtnlotus.com/uv/pco/Library/FHIRHelpers|4.4.000"
},
{
"type" : "depends-on",
"display" : "Library PC",
"resource" : "http://mtnlotus.com/uv/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://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset"
},
{
"type" : "depends-on",
"display" : "Value set Goal Attainment Scaling (GAS) Score",
"resource" : "http://mtnlotus.com/uv/pco/ValueSet/goal-attainment-scaling-score"
},
{
"type" : "depends-on",
"display" : "Value set PROM Target Measures",
"resource" : "http://mtnlotus.com/uv/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://mtnlotus.com/uv/pco/ValueSet/goal-attainment-scaling-score"
}
]
},
{
"type" : "Observation",
"profile" : [
🔗 "http://hl7.org/fhir/StructureDefinition/Observation"
],
"mustSupport" : [
"code"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://mtnlotus.com/uv/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://mtnlotus.com/uv/pco/Measure/GoalFollowUpMeasure",
"identifier" : [
{
"use" : "usual",
"type" : {
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"code" : "short-name"
}
]
},
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"value" : "PCOMeasure1"
},
{
"use" : "official",
"type" : {
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{
"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"
},
{
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"type" : {
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"code" : "version-specific"
}
]
},
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"value" : "urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05"
},
{
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"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" : "2024-09-22T11:23:29+00:00",
"publisher" : "Mountain Lotus WellBeing LLC",
"contact" : [
{
"name" : "Mountain Lotus WellBeing LLC",
"telecom" : [
{
"system" : "url",
"value" : "http://mtnlotus.com"
}
]
}
],
"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" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
"code" : "001",
"display" : "World"
}
]
}
],
"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" : "Mountain Lotus WellBeing LLC",
"telecom" : [
{
"system" : "url",
"value" : "https://www.mtnlotus.com/"
}
]
}
],
"library" : [
🔗 "http://mtnlotus.com/uv/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+ Mountain Lotus WellBeing LLC. Package mtnlotus.fhir.uv.pco#0.2.0 based on FHIR 4.0.1. Generated 2024-10-25
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