Person-Centered Outcomes
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Person-Centered Outcomes, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/mtnlotus/pco-ig/ and changes regularly. See the Directory of published versions

Artifacts Summary

Contents:

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Knowledge Artifacts: Measure

These define measures as part of content in this implementation guide.

Person-Centered Goal Follow-Up

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.
Person-Centered Goal Identification

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

Knowledge Artifacts: Libraries

These define logic, asset collections and other libraries as part of content in this implementation guide.

FHIRHelpers
GoalAttainmentLogic
GoalFollowUpMeasure
GoalIdentificationMeasure
PCOCommon
WhatMattersLogic

Structures: Questionnaires

These define forms used by systems conforming to this implementation guide to capture or expose data to end users.

Generalized anxiety disorder 7 item
PHQ-9 quick depression assessment panel

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide.

Goal Attainment Scaling (GAS) score

The follow-up score indicates how a patient, caregiver, or practitioner rated progress on goal attainment scaling.
Patient-Reported Outcome Measure (PROM) score

This observation records how a patient's progress score is rated using a PROM assessment.
Person-Centered Care Plan

A person-centered care plan SHALL reference a person-centered goal and SHALL include action steps that support progress toward achievement of the plan's goals and desired outcomes. A plan SHOULD address the person's stated priorities for what matters most to them. Action steps may include both treatment procedures and self-care steps identified by the person.
Person-Centered GAS Goal

Person-centered goal with goal attainment scaling.
Person-Centered Goal

Person-centered goal focused on what matters most to an individual. A Person-centered goal SHALL include either a Person-Centered Outcome category, or address a What Matters assessment.
Person-Centered PROM Goal

Person-centered goal with a Patient-Reported Outcome Measure (PROM) score target.
What Matters Assessment

Assessment observation for one aspect of What Matters Most to a person, with component values rating where a person is now and where they would like to be in the future.
What Matters Priority

Assessment observation for one aspect of What Matters Most to a person, with a boolean value indicating whether this is a current priority.
What Matters Statement

Assessment observation for one aspect of What Matters Most to a person, with a text statement about a focus area.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide.

Goal Attainment Scaling

Goal Attainment Scaling (GAS) is an extension used to specify five levels of attainment for a person-centered goal.

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide.

Follow-Up GAS Score Answers

The progress rating on goal attainment scaling.
Goal Attainment Scaling (GAS) Score

The score indicates how a patient, caregiver, or practitioner rated progress on goal attainment scaling.
PCO Domain Categories

Example value set to identify the domains category for PCO resources.
PROM Target Measures

Target measure codes used to track progress on patient-reported outcome measures (PROMs).
Well-Being Domains Example

Example value set containing well-being domains from the VA Circle of Health.

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide.

Codes for PCO

Codes to identify content associated with this IG
PCO Goal Domains

Goal domain codes used to identify the category for PCO resources.
VA Whole Health Concepts

Code system to identify "What Matters" concepts from the VA Whole Health appraoch and Circle of Health.
Well-Being Concepts

Code system to identify resource codes and category domains for "What Matters".

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.

Care Plan for PCO Anxiety Goal

Care Plan for a person-centered goal using a PROM score measure.
Care Plan for person-centered goal

Care Plan for a person-centered goal with action steps for achieving what matters most to that person.
Care Plan: Action step for mindfulness program

Care Plan activity: Mindfulness coaching to support anxiety management
Care Plan: Anti-Inflammatory Medication

Care Plan activity: Anti-inflammatory gel for knee pain to enable walking
Care Plan: Clinical action step for PT

Care Plan activity: Physical therapy to relieve pain related to walking
Care Plan: Personal action step

Care Plan activity: Initial personal action step toward goal of walking dog outside
Example Patient Camila

Camila Lopez
Example Patient Dorothy

Dorothy Jones
GAD-7 PROM Follow-up Score

Follow-up GAD-7 PROM score observation recorded by a Patient showing goal progress.
GAS Baseline Score

Baseline GAS score observation at start of goal.
Goal for GAD-7 PROM Outcome

Person-centered goal with a PROM outcome target for GAD-7 score.
Goal with GAS

Person-centered goal with attainment scaling extensions
Goal without GAS Extensions

Person-centered goal with GAS target measure and without GAS extensions
Goal without GAS or PROM

Person-centered goal without attainment scaling or PROM
Health & Wellness Coach

Maria Gonzalez, NBC-HWC
Patient GAS Follow-up Score

Follow-up GAS score observation recorded by a Patient showing goal progress.
Practitioner GAS Follow-up Score

Follow-up GAS score observation recorded by a Practitioner showing goal progress.
Primary Care Physician

John Anderson, MD
What Matters Priority: Moving the Body

What Matters observation recorded by a Patient to indicate their priority for well-being.
What Matters Statement: Family & Friends

What Matters observation added by a Patient to record a statement about a well-being focus area.
What Matters: Family & Friends

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.
What Matters: Moving the Body

What Matters assessment observation recorded by a Patient as preparation for creating PCO goals and CarePlan action steps.

Other

These are resources that are used within this implementation guide that do not fit into one of the other categories.

cqf-tooling