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 |
<Measure xmlns="http://hl7.org/fhir">
<id value="GoalFollowUpMeasure"/>
<meta>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"/>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm"/>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table class="grid dict">
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">Person-Centered Goal Follow-Up</td>
</tr>
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">GoalFollowUpMeasure</td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">0.2.0</td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;"><a href="Measure-GoalFollowUpMeasure.html">Person-Centered Goal Follow-Up</a></td>
</tr>
<tr>
<th scope="row">
<b>
short-name identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>PCOMeasure1</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
version-independent identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
version-specific identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
publisher (CMS) identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>NA</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Effective Period: </b></th>
<td style="padding-left: 4px;">2024-01-01..2024-12-31</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">Mountain Lotus WellBeing LLC</td>
</tr>
<tr>
<th scope="row"><b>Author: </b></th>
<td style="padding-left: 4px;">Mountain Lotus WellBeing LLC</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<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>
</div></td>
</tr>
<tr>
<th scope="row"><b>Jurisdiction: </b></th>
<td style="padding-left: 4px;">001</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<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>
</div></td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<td style="padding-left: 4px;"><div><p>Measure definition is copyright 2024 by NCQA.</p>
<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>
</div></td>
</tr>
<tr>
<th scope="row"><b>Disclaimer: </b></th>
<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>
</div></td>
</tr>
<tr>
<th scope="row"><b>Scoring: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Proportion </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Rationale: </b></th>
<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>
</div></td>
</tr>
<tr>
<th scope="row"><b>Clinical recommendation statement: </b></th>
<td style="padding-left: 4px;"><div><p>None at this time.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Guidance (Usage): </b></th>
<td style="padding-left: 4px;">Content TBD.</td>
</tr>
<tr>
<th scope="row"><b>Population Criteria: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>64f0d91d56d636294b157d97</b></th>
</tr>
<tr>
<td>Initial Population:</td>
<td>Individuals 18 years of age and older.</td>
</tr>
<tr>
<td>Denominator:</td>
<td>Individuals 18 years of age and older with a complex care need and has a PCO Goal.</td>
</tr>
<tr>
<td>Denominator Exclusion:</td>
<td>None</td>
</tr>
<tr>
<td>Numerator:</td>
<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>
</tr>
<tr>
<td>Denominator Exception:</td>
<td>None</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Libraries: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<td><a href="Library-GoalFollowUpMeasure.html">GoalFollowUpMeasure</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Terminology and Other Dependencies: </b></th>
<td style="padding-left: 4px;">
<li><code>http://mtnlotus.com/uv/pco/Library/GoalAttainmentLogic|0.1.0</code></li>
<li><code>http://mtnlotus.com/uv/pco/Library/FHIRHelpers|4.4.000</code></li>
<li><code>http://mtnlotus.com/uv/pco/Library/PCOCommon|0.1.0</code></li>
<li><a href="http://terminology.hl7.org/5.2.0/CodeSystem-v3-loinc.html">Logical Observation Identifiers, Names and Codes (LOINC)</a></li>
<li><a href="ValueSet-pco-category-valueset.html">PCO Categories</a></li>
<li><a href="ValueSet-goal-attainment-scaling-score.html">Goal Attainment Scaling (GAS) Score</a></li>
<li><a href="ValueSet-prom-target-measures.html">PROM Target Measures</a></li>
</td>
</tr>
<tr>
<th scope="row"><b>Parameters:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>name</b></th>
<th><b>use</b></th>
<th><b>min</b></th>
<th><b>max</b></th>
<th><b>type</b></th>
</tr>
<tr>
<td>Measurement Period</td>
<td>In</td>
<td>0</td>
<td>1</td>
<td>Period</td>
</tr>
<tr>
<td>Follow-Up Interval</td>
<td>In</td>
<td>0</td>
<td>1</td>
<td>Range</td>
</tr>
<tr>
<td>Numerator</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Patient</td>
</tr>
<tr>
<td>Denominator</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Patient</td>
</tr>
<tr>
<td>Initial Population</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Patient</td>
</tr>
<tr>
<td>Denominator Exclusions</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>Resource</td>
</tr>
<tr>
<td>Denominator Exceptions</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>Resource</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>DataRequirements:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>Resource Type</b></th>
<th><b>Resource Elements</b></th>
<th><b>Valueset Name</b></th>
<th><b>Valueset</b></th>
</tr>
<tr>
<td>Patient(<a href="http://hl7.org/fhir/R4/patient.html">Patient</a>)</td>
<td>
</td>
<td>
</td>
<td/>
</tr>
<tr>
<td>Goal(<a href="http://hl7.org/fhir/R4/goal.html">Goal</a>)</td>
<td>
category
start
measure
id
</td>
<td>
</td>
<td/>
</tr>
<tr>
<td>Observation(<a href="http://hl7.org/fhir/R4/observation.html">Observation</a>)</td>
<td>
code
</td>
<td>
Goal Attainment Scaling (GAS) Score
</td>
<td><a href="ValueSet-goal-attainment-scaling-score.html">Goal Attainment Scaling (GAS) Score</a></td>
</tr>
<tr>
<td>Observation(<a href="http://hl7.org/fhir/R4/observation.html">Observation</a>)</td>
<td>
code
</td>
<td>
PROM Target Measures
</td>
<td><a href="ValueSet-prom-target-measures.html">PROM Target Measures</a></td>
</tr>
<tr>
<td>CarePlan(<a href="http://hl7.org/fhir/R4/careplan.html">CarePlan</a>)</td>
<td>
goal
</td>
<td>
</td>
<td/>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Direct Reference Codes:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>display</b></th>
<th><b>code</b></th>
<th><b>system</b></th>
</tr>
<tr>
<td>Goal attainment scale</td>
<td>68489</td>
<td><a href="http://terminology.hl7.org/6.0.2/CodeSystem-v3-loinc.html">http://loinc.org</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Logic Definitions:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>Group</b></th>
<th><b>Scoring</b></th>
<th><b>Population Criteria</b></th>
<th><b>Expression</b></th>
</tr>
<tr>
<td> 64f0d91d56d636294b157d97 </td>
<td colspan="3" style="padding-left: 4px;">
<b>Measure scoring:</b>
<p style="margin-bottom: 5px;">
<span>Proportion</span>
</p>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Process </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Rate Aggregation: </b></th>
<td colspan="3" style="padding-left: 4px;">None</td>
</tr>
<tr>
<th scope="row"><b>Improvement Notation: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Increased score indicates improvement </span>
</p>
</td>
</tr>
</td>
<tr>
<td/>
<td/>
<td>Initial Population</td>
<td>
<pre><code class="language-cql">/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
Patient person
where AgeInYearsAt(start of "Measurement Period") >= 18
}</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator</td>
<td>
<pre><code class="language-cql">/*
@description: Initial Population individuals with a complex care need and has a PCO Goal.
@comment: TODO - How do we determine "complex care need?"
*/
define "Denominator":
"Initial Population"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator Exclusion</td>
<td>
<pre><code class="language-cql">define "Denominator Exclusions":
null</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Numerator</td>
<td>
<pre><code class="language-cql">/*
@description: Indivuals who received follow-up on their PCO goal within two
weeks to six months of when the PCO goal and GAS or PROM were identified.
*/
define "Numerator":
"Denominator" person
where exists PCOLogic."Follow-Up Scores During Measurement Period"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator Exception</td>
<td>
<pre><code class="language-cql">define "Denominator Exceptions":
null</code></pre>
</td>
</tr>
</tr>
</table>
<table class="grid-dict">
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalFollowUpMeasure</td>
<td>Initial Population</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
Patient person
where AgeInYearsAt(start of "Measurement Period") >= 18
}</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalFollowUpMeasure</td>
<td>Denominator</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
@description: Initial Population individuals with a complex care need and has a PCO Goal.
@comment: TODO - How do we determine "complex care need?"
*/
define "Denominator":
"Initial Population"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>PCO Goals</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
A "PCO Goal" is any FHIR Goal that has a category in "PCO Categories"
and has a start date.
TODO: or a Goal that addresses a What Matters observation.
*/
define "PCO Goals":
[Goal] goal
where goal.category in "PCO Categories"
and (goal.start as FHIR.date) is not null</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>GAS Scores</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Observations containing a GAS score.
define "GAS Scores":
[Observation: "Goal Attainment Scaling (GAS) Score"]</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>PCO Goals During Measurement Period</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// PCO Goals whose startDate falls within the Measurement Period
define "PCO Goals During Measurement Period":
"PCO Goals" goal
where (ToDateTime(goal.start as FHIR.date) during "Measurement Period")
and (goal.hasGAS() or goal.hasPROM())
and exists goal.carePlans()</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>PROM Scores</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Observations containing a PROM score.
define "PROM Scores":
[Observation: "PROM Target Measures"]</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>Follow-Up Scores During Measurement Period</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
Follow-Up Scares are PCO score observations taken during the Measurement Period,
and during the follow-up period for its Goal. Default follow-up period is
2 weeks to 6 months following the goal startDate.
*/
define "Follow-Up Scores During Measurement Period":
flatten( "PCO Goals During Measurement Period" goal
let pcoScores: goal.pcoScores()
return pcoScores score
let scoreDate: score.effective as FHIR.dateTime
where scoreDate during "Measurement Period"
and scoreDate during "Follow-Up Interval For"(goal)
)</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalFollowUpMeasure</td>
<td>Numerator</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
@description: Indivuals who received follow-up on their PCO goal within two
weeks to six months of when the PCO goal and GAS or PROM were identified.
*/
define "Numerator":
"Denominator" person
where exists PCOLogic."Follow-Up Scores During Measurement Period"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalFollowUpMeasure</td>
<td>Denominator Exclusions</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Denominator Exclusions":
null</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalFollowUpMeasure</td>
<td>Denominator Exceptions</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Denominator Exceptions":
null</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>FHIRHelpers</td>
<td>ToConcept</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
if concept is null then
null
else
System.Concept {
codes: concept.coding C return ToCode(C),
display: concept.text.value
}</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>FHIRHelpers</td>
<td>ToDate</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define function ToDate(value date): value.value</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>hasGAS</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// where exists obs.performer.resolveRelatedPersons()
define fluent function hasGAS(goal Goal):
exists goal.extensions('http://mtnlotus.com/uv/pco/StructureDefinition/pco-goal-attainment-scaling')
or exists (goal.target target
where target.measure = "Goal attainment scale"
)
or exists goal.gasScores()</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>PCOCommon</td>
<td>extensions</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
@description: Returns any extensions defined on the given resource with the specified url.
@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define fluent function extensions(domainResource DomainResource, url String):
domainResource.extension E
where E.url = url
return E</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>FHIRHelpers</td>
<td>ToString</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define function ToString(value uri): value.value</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>gasScores</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Returns a list of Observation including only GAS scores
define fluent function gasScores(goal Goal):
"GAS Scores" score
where score.focusGoals() contains goal</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>focusGoals</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Returns a list of Goal where focus includes the given Observation.
define fluent function focusGoals(obs Observation):
obs.focus.resolveGoals()</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>PCOCommon</td>
<td>resolveGoals</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define fluent function resolveGoals(references List<Reference>):
flatten( references ref
return [Goal] resource
where resource.id = ref.reference.getId()
)</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>PCOCommon</td>
<td>getId</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define fluent function getId(uri String):
Last(Split(uri, '/'))</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>hasPROM</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/// Returns true if this Goal has a PROM code in its target.measure
define fluent function hasPROM(goal Goal):
exists (goal.target target
where target.measure in "PROM Target Measures"
)</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>PCOCommon</td>
<td>carePlans</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Returns a list of CarePlan that support this Goal.
define fluent function carePlans(goal Goal):
[CarePlan] carePlan
where exists ( carePlan.goal goalRef
where goal.id = goalRef.reference.getId()
)</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>pcoScores</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Returns a list of Observation including both GAS and PROM scores
define fluent function pcoScores(goal Goal):
goal.gasScores()
union goal.promScores()</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>promScores</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// Returns a list of Observation including only PROM scores
define fluent function promScores(goal Goal):
"PROM Scores" score
where score.focusGoals() contains goal</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>FHIRHelpers</td>
<td>ToDateTime</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define function ToDateTime(value dateTime): value.value</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>GoalAttainmentLogic</td>
<td>Follow-Up Interval For</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">/*
Computes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter.
@return Interval<DateTime>
*/
define function "Follow-Up Interval For" (goal Goal):
goal goal
let startDate: ToDateTime(goal.start as FHIR.date)
return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval")</code></pre>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements"/>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system value="http://loinc.org"/>
<code value="68489"/>
<display value="Goal attainment scale"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalFollowUpMeasure"/>
</extension>
<extension url="name">
<valueString value="Initial Population"/>
</extension>
<extension url="statement">
<valueString
value="/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
Patient person
where AgeInYearsAt(start of "Measurement Period") >= 18
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalFollowUpMeasure"/>
</extension>
<extension url="name">
<valueString value="Denominator"/>
</extension>
<extension url="statement">
<valueString
value="/*
@description: Initial Population individuals with a complex care need and has a PCO Goal.
@comment: TODO - How do we determine "complex care need?"
*/
define "Denominator":
"Initial Population""/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="PCO Goals"/>
</extension>
<extension url="statement">
<valueString
value="/*
A "PCO Goal" is any FHIR Goal that has a category in "PCO Categories"
and has a start date.
TODO: or a Goal that addresses a What Matters observation.
*/
define "PCO Goals":
[Goal] goal
where goal.category in "PCO Categories"
and (goal.start as FHIR.date) is not null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="GAS Scores"/>
</extension>
<extension url="statement">
<valueString
value="// Observations containing a GAS score.
define "GAS Scores":
[Observation: "Goal Attainment Scaling (GAS) Score"]"/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="PCO Goals During Measurement Period"/>
</extension>
<extension url="statement">
<valueString
value="// PCO Goals whose startDate falls within the Measurement Period
define "PCO Goals During Measurement Period":
"PCO Goals" goal
where (ToDateTime(goal.start as FHIR.date) during "Measurement Period")
and (goal.hasGAS() or goal.hasPROM())
and exists goal.carePlans()"/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="PROM Scores"/>
</extension>
<extension url="statement">
<valueString
value="// Observations containing a PROM score.
define "PROM Scores":
[Observation: "PROM Target Measures"]"/>
</extension>
<extension url="displaySequence">
<valueInteger value="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="Follow-Up Scores During Measurement Period"/>
</extension>
<extension url="statement">
<valueString
value="/*
Follow-Up Scares are PCO score observations taken during the Measurement Period,
and during the follow-up period for its Goal. Default follow-up period is
2 weeks to 6 months following the goal startDate.
*/
define "Follow-Up Scores During Measurement Period":
flatten( "PCO Goals During Measurement Period" goal
let pcoScores: goal.pcoScores()
return pcoScores score
let scoreDate: score.effective as FHIR.dateTime
where scoreDate during "Measurement Period"
and scoreDate during "Follow-Up Interval For"(goal)
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalFollowUpMeasure"/>
</extension>
<extension url="name">
<valueString value="Numerator"/>
</extension>
<extension url="statement">
<valueString
value="/*
@description: Indivuals who received follow-up on their PCO goal within two
weeks to six months of when the PCO goal and GAS or PROM were identified.
*/
define "Numerator":
"Denominator" person
where exists PCOLogic."Follow-Up Scores During Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalFollowUpMeasure"/>
</extension>
<extension url="name">
<valueString value="Denominator Exclusions"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator Exclusions":
null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalFollowUpMeasure"/>
</extension>
<extension url="name">
<valueString value="Denominator Exceptions"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator Exceptions":
null"/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToConcept"/>
</extension>
<extension url="statement">
<valueString
value="/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
if concept is null then
null
else
System.Concept {
codes: concept.coding C return ToCode(C),
display: concept.text.value
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToDate"/>
</extension>
<extension url="statement">
<valueString
value="define function ToDate(value date): value.value"/>
</extension>
<extension url="displaySequence">
<valueInteger value="11"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="hasGAS"/>
</extension>
<extension url="statement">
<valueString
value="// where exists obs.performer.resolveRelatedPersons()
define fluent function hasGAS(goal Goal):
exists goal.extensions('http://mtnlotus.com/uv/pco/StructureDefinition/pco-goal-attainment-scaling')
or exists (goal.target target
where target.measure = "Goal attainment scale"
)
or exists goal.gasScores()"/>
</extension>
<extension url="displaySequence">
<valueInteger value="12"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="PCOCommon"/>
</extension>
<extension url="name">
<valueString value="extensions"/>
</extension>
<extension url="statement">
<valueString
value="/*
@description: Returns any extensions defined on the given resource with the specified url.
@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define fluent function extensions(domainResource DomainResource, url String):
domainResource.extension E
where E.url = url
return E"/>
</extension>
<extension url="displaySequence">
<valueInteger value="13"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToString"/>
</extension>
<extension url="statement">
<valueString
value="define function ToString(value uri): value.value"/>
</extension>
<extension url="displaySequence">
<valueInteger value="14"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="gasScores"/>
</extension>
<extension url="statement">
<valueString
value="// Returns a list of Observation including only GAS scores
define fluent function gasScores(goal Goal):
"GAS Scores" score
where score.focusGoals() contains goal"/>
</extension>
<extension url="displaySequence">
<valueInteger value="15"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="focusGoals"/>
</extension>
<extension url="statement">
<valueString
value="// Returns a list of Goal where focus includes the given Observation.
define fluent function focusGoals(obs Observation):
obs.focus.resolveGoals()"/>
</extension>
<extension url="displaySequence">
<valueInteger value="16"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="PCOCommon"/>
</extension>
<extension url="name">
<valueString value="resolveGoals"/>
</extension>
<extension url="statement">
<valueString
value="define fluent function resolveGoals(references List<Reference>):
flatten( references ref
return [Goal] resource
where resource.id = ref.reference.getId()
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="17"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="PCOCommon"/>
</extension>
<extension url="name">
<valueString value="getId"/>
</extension>
<extension url="statement">
<valueString
value="define fluent function getId(uri String):
Last(Split(uri, '/'))"/>
</extension>
<extension url="displaySequence">
<valueInteger value="18"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="hasPROM"/>
</extension>
<extension url="statement">
<valueString
value="/// Returns true if this Goal has a PROM code in its target.measure
define fluent function hasPROM(goal Goal):
exists (goal.target target
where target.measure in "PROM Target Measures"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="19"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="PCOCommon"/>
</extension>
<extension url="name">
<valueString value="carePlans"/>
</extension>
<extension url="statement">
<valueString
value="// Returns a list of CarePlan that support this Goal.
define fluent function carePlans(goal Goal):
[CarePlan] carePlan
where exists ( carePlan.goal goalRef
where goal.id = goalRef.reference.getId()
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="20"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="pcoScores"/>
</extension>
<extension url="statement">
<valueString
value="// Returns a list of Observation including both GAS and PROM scores
define fluent function pcoScores(goal Goal):
goal.gasScores()
union goal.promScores()"/>
</extension>
<extension url="displaySequence">
<valueInteger value="21"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="promScores"/>
</extension>
<extension url="statement">
<valueString
value="// Returns a list of Observation including only PROM scores
define fluent function promScores(goal Goal):
"PROM Scores" score
where score.focusGoals() contains goal"/>
</extension>
<extension url="displaySequence">
<valueInteger value="22"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="FHIRHelpers"/>
</extension>
<extension url="name">
<valueString value="ToDateTime"/>
</extension>
<extension url="statement">
<valueString
value="define function ToDateTime(value dateTime): value.value"/>
</extension>
<extension url="displaySequence">
<valueInteger value="23"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="GoalAttainmentLogic"/>
</extension>
<extension url="name">
<valueString value="Follow-Up Interval For"/>
</extension>
<extension url="statement">
<valueString
value="/*
Computes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter.
@return Interval<DateTime>
*/
define function "Follow-Up Interval For" (goal Goal):
goal goal
let startDate: ToDateTime(goal.start as FHIR.date)
return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval")"/>
</extension>
<extension url="displaySequence">
<valueInteger value="24"/>
</extension>
</extension>
<name value="EffectiveDataRequirements"/>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/library-type"/>
<code value="module-definition"/>
</coding>
</type>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library PCOLogic"/>
<resource
value="http://mtnlotus.com/uv/pco/Library/GoalAttainmentLogic|0.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library FHIRHelpers"/>
<resource
value="http://mtnlotus.com/uv/pco/Library/FHIRHelpers|4.4.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library PC"/>
<resource value="http://mtnlotus.com/uv/pco/Library/PCOCommon|0.1.0"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Code system LOINC"/>
<resource value="http://loinc.org"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set PCO Categories"/>
<resource
value="http://mtnlotus.com/uv/pco/ValueSet/pco-category-valueset"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Goal Attainment Scaling (GAS) Score"/>
<resource
value="http://mtnlotus.com/uv/pco/ValueSet/goal-attainment-scaling-score"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set PROM Target Measures"/>
<resource
value="http://mtnlotus.com/uv/pco/ValueSet/prom-target-measures"/>
</relatedArtifact>
<parameter>
<name value="Measurement Period"/>
<use value="in"/>
<min value="0"/>
<max value="1"/>
<type value="Period"/>
</parameter>
<parameter>
<name value="Follow-Up Interval"/>
<use value="in"/>
<min value="0"/>
<max value="1"/>
<type value="Range"/>
</parameter>
<parameter>
<name value="Numerator"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Patient"/>
</parameter>
<parameter>
<name value="Denominator"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Patient"/>
</parameter>
<parameter>
<name value="Initial Population"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Patient"/>
</parameter>
<parameter>
<name value="Denominator Exclusions"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="Resource"/>
</parameter>
<parameter>
<name value="Denominator Exceptions"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="Resource"/>
</parameter>
<dataRequirement>
<type value="Patient"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Patient"/>
</dataRequirement>
<dataRequirement>
<type value="Goal"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Goal"/>
<mustSupport value="category"/>
<mustSupport value="start"/>
<mustSupport value="measure"/>
<mustSupport value="id"/>
</dataRequirement>
<dataRequirement>
<type value="Observation"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
<mustSupport value="code"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://mtnlotus.com/uv/pco/ValueSet/goal-attainment-scaling-score"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Observation"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
<mustSupport value="code"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://mtnlotus.com/uv/pco/ValueSet/prom-target-measures"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="CarePlan"/>
<profile value="http://hl7.org/fhir/StructureDefinition/CarePlan"/>
<mustSupport value="goal"/>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem">
<valueReference>🔗
<reference value="Device/cqf-tooling"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements" id="effective-data-requirements">
<valueReference>
<reference value="#effective-data-requirements"/>
</valueReference>
</extension>
<url value="http://mtnlotus.com/uv/pco/Measure/GoalFollowUpMeasure"/>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="short-name"/>
</coding>
</type>
<system value="https://madie.cms.gov/measure/shortName"/>
<value value="PCOMeasure1"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="version-independent"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="version-specific"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="publisher"/>
</coding>
</type>
<system value="https://madie.cms.gov/measure/cmsId"/>
<value value="NA"/>
<assigner>
<display value="CMS"/>
</assigner>
</identifier>
<version value="0.2.0"/>
<name value="GoalFollowUpMeasure"/>
<title value="Person-Centered Goal Follow-Up"/>
<status value="active"/>
<experimental value="false"/>
<date value="2024-09-22T11:23:29+00:00"/>
<publisher value="Mountain Lotus WellBeing LLC"/>
<contact>
<name value="Mountain Lotus WellBeing LLC"/>
<telecom>
<system value="url"/>
<value value="http://mtnlotus.com"/>
</telecom>
</contact>
<description
value="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 value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
<code value="001"/>
<display value="World"/>
</coding>
</jurisdiction>
<purpose
value="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 value="Content TBD."/>
<copyright
value="Measure definition is copyright 2024 by NCQA.
LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved."/>
<effectivePeriod>
<start value="2024-01-01"/>
<end value="2024-12-31"/>
</effectivePeriod>
<author>
<name value="Mountain Lotus WellBeing LLC"/>
<telecom>
<system value="url"/>
<value value="https://www.mtnlotus.com/"/>
</telecom>
</author>
<library value="http://mtnlotus.com/uv/pco/Library/GoalFollowUpMeasure"/>
<disclaimer
value="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 value="http://terminology.hl7.org/CodeSystem/measure-scoring"/>
<code value="proportion"/>
<display value="Proportion"/>
</coding>
</scoring>
<rationale
value="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 value="None at this time."/>
<group id="64f0d91d56d636294b157d97">
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis">
<valueCode value="Patient"/>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-type">
<valueCodeableConcept>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-type"/>
<code value="process"/>
<display value="Process"/>
</coding>
</valueCodeableConcept>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-rateAggregation">
<valueString value="None"/>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-improvementNotation">
<valueCodeableConcept>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
<code value="increase"/>
<display value="Increased score indicates improvement"/>
</coding>
</valueCodeableConcept>
</extension>
<description value="Content TBD"/>
<population id="692C6F6B-4153-496F-8582-0839A0816567">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="initial-population"/>
<display value="Initial Population"/>
</coding>
</code>
<description value="Individuals 18 years of age and older."/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Initial Population"/>
</criteria>
</population>
<population id="3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator"/>
<display value="Denominator"/>
</coding>
</code>
<description
value="Individuals 18 years of age and older with a complex care need and has a PCO Goal."/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator"/>
</criteria>
</population>
<population id="AA76FF0E-0EF9-40E6-9913-90FA63D50298">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exclusion"/>
<display value="Denominator Exclusion"/>
</coding>
</code>
<description value="None"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exclusions"/>
</criteria>
</population>
<population id="3D2BED97-5ADC-4210-8A3E-91B13652E7D0">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="numerator"/>
<display value="Numerator"/>
</coding>
</code>
<description
value="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 value="text/cql-identifier"/>
<expression value="Numerator"/>
</criteria>
</population>
<population id="4511743B-B054-4A08-800B-C4624450C38C">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exception"/>
<display value="Denominator Exception"/>
</coding>
</code>
<description value="None"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exceptions"/>
</criteria>
</population>
</group>
</Measure>
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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