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

Use Cases

Identifying What Matters Most

More detail coming soon!

Many alternative tools have been developed and are in use that enable individuals to reflect on What Matters Most for their health & well-being. One example is the U.S. Department of Veterns Affairs Whole Health appoach to care that includes a Circle of Health and Personal Health Inventory. The examples in this FHIR IG are based on VA’s approach, but can be adapted to other asseessments used by different organizations.

Goal Attainment Scaling (GAS)

More detail coming soon!

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. GAS involves collaboratively setting goals with the individual and assigning numerical scales to each goal to represent different levels of achievement. This approach provides a more nuanced and tailored way to assess progress and outcomes, taking into account the unique circumstances and aspirations of the individual.

Goals with GAS from real-world NCQA pilot testing

🎯 Goal: To get out more and engage in more social activity since spouse’s death
Goal Domain: Social & Role Functioning

Much Less Than Expected (-2)	Less Than Expected (-1)	Expected Outcome (0)	Better Than Expected (+1)	Much Better Than Expected (+2)
Get out of house only a few times a month	Get out of the house less than once a week	Get out of the house 1-2 times per week in the next month	Get out of the house more than 2 times per week in the next month	Get out of house more than 4 times per week in the next month

🎯 Goal: Walk 15 minutes 2x/week for 3 months to improve mobility
Goal Domain: Physical Function

Much Less Than Expected (-2)	Less Than Expected (-1)	Expected Outcome (0)	Better Than Expected (+1)	Much Better Than Expected (+2)
Unable to walk once per week	Walk 10 minutes 1x/week	Walk 15 minutes 2x/week for the next 3 months	Walk 15 minutes 3x/week for the next 3 months	Walk 15 minutes 4x/week for the next 3 months

Goals using Patient-Reported Outcome Measures (PROM)

More detail coming soon!

Based in psychometric science, Patient-Reported Outcome Measures (PROMs) are standardized questionnaires that contain multiple questions, or items, patients answer on their own to generate numerical scores measuring symptoms, function, perceived health status. Two examples of commonly used PROMs are PHQ-9 quick depression assessment panel and Generalized Anxiety Disorder (GAD-7).

PCO Digital Quality Measures (dQM)

More detail coming soon!

Examples of PCO dQMs:

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.

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.

Measure 3: Goal Achievement

% of individuals 18 years of age or older with a complex care need who achieved their PCO goal within two weeks to six months of when the PCO goal and GAS or PROM were identified.

PCO Data Submission: Bundles

Profile Specification and examples are still under development.

This section is inspired by a similar data submission bundle in the draft Argo CCM Write FHIR IG.

Technical Details

• PCO Submitters and Receivers SHALL support bundle-based submission, and MAY support individual resource submission
• PCO Receivers MAY choose to store only a subset of resources in a submitted bundle
  • Each entry in the batch-response bundle SHALL provide a status code indicating whether the submission was accepted
  • Accepted entries SHOULD be available for read/search immediately after submission, but MAY be subjected to additional ingestion workflow steps

Actors

PCO Data Submitter

The data submitter is a software system that collects and manages PCO data. It typically incorporates a patient-facing app, and may also incorporate a clinician-facing EHR-integrated app and a cloud service.

This IG also refers to Data Submitters as “apps”.

PCO Data Receiver

The data receiver is a software system that receives and stores the PCO data submitted by the data submitter.

This IG also refers to Data Receivers as “EHRs” or “PCO management platforms”.

PCO Measure Performer

The measure performer is a software system that receives the PCO data and computes digital quality measures for a population of individuals.