PACIO Personal Functioning and Engagement Implementation Guide
2.0.0 - STU 2
PACIO Personal Functioning and Engagement Implementation Guide
2.0.0 - STU 2
This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/pacio-pfe/ImplementationGuide/hl7.fhir.us.pacio-pfe | Version: 2.0.0 | |||
| IG Standards status: Trial-use Active as of 2025-07-23 | Maturity Level: 3 | Computable Name: PACIOPersonalFunctioningAndEngagementImplementationGuide | ||
HL7, which stands for Health Level Seven, creates standards to help different healthcare computer systems talk to each other. These HL7 standards are a special language or set of rules that lets information be shared between hospitals, doctors’ offices (e.g. Electronic Health Record Systems), labs, patients (e.g. via patient portals), pharmacies, and insurers, among others.
One of the HL7 standards is HL7 FHIR (Fast Healthcare Interoperability Resources). It helps connect healthcare systems, making it easier for doctors, nurses, and other healthcare professionals to share important information about patients. For example, if you have a lab test at a hospital, HL7 FHIR helps send the results to your doctor’s office so they can provide the right care.
A goal of HL7 is to make sure everyone involved in your healthcare has the right information at the right time. Our standards help machines and people, including you, work together to make better decisions for your health. HL7 sets rules that computer systems follow, so they can understand and share information in a consistent and reliable way.
To learn more about HL7, you can visit the website hl7.org
The people at HL7 make guides that explain how to use the rules (standards) for different things. These guides bring the rules together and show how to use them for specific purposes.
The PACIO Personal Functioning and Engagement (PFE) Implementation Guide helps healthcare providers share information about how people live their daily lives. It focuses on understanding what people can do, what challenges they face, and how their environment affects them. This guide uses a system called FHIR to organize and share this information in a clear and consistent way.
The guide is based on the International Classification of Functioning, Disability, and Health (ICF), which groups information into four main areas:
Based on the ICF category, the PFE implementation guide can recommend a short list of codes for caregivers to describe what they observed about the patient. This reduces the burden on caregivers because they have a smaller set of data that only has what they need.
This guide makes it easier for doctors, caregivers, and others to work together and plan care that fits the patient's needs. By sharing this information in a standard way, everyone involved can better understand how to help the patient live their best life.
In short, the PFE guide helps healthcare focus on the whole person—not just their medical problems—so they can stay active and engaged in life.
The Personal Functioning and Engagement (PFE) HL7® FHIR® Implementation Guide (IG) supports the exchange of information related to a person's ability to participate in activities and interact with their community and the environment around them. The three words in the title frame aspects of the intended scope for this IG:
After a patient receives care in an acute hospital setting, they may move into post-acute care (PAC) settings like long-term care facilities (e.g., skilled nursing or assisted living facilitates) before going back into their homes and communities where they will manage their health themselves and with support from others (e.g., family, home health aides, community organizations that support basic needs). In these settings, the focus of their healthcare providers and caregivers is to: (1) deliver therapies and treatments; and (2) identify supports that will help the patient successfully engage in daily life at home and in the community.
While a patient is in long-term care, healthcare providers from many disciplines - including physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, and social workers - use formal and informal assessments and observations to answer questions that can help them prepare a person to return home, such as:
Healthcare providers record assessments and observations in an electronic health record, which their colleagues and their organization can use for tracking improvement, care planning, and reimbursement purposes. Access to this information is critical for other healthcare providers and organizations across the full spectrum of the person's care, including acute care, primary care, and home- and community-based services, to support care coordination across settings.
Unfortunately, healthcare providers across the spectrum of care, including at long-term care facilities and down-stream settings such as home- and community-based services, often face challenges sharing important assessment and observation data with and obtaining it from other healthcare providers involved in the person’s care. Forty-five percent of Medicare beneficiaries require post-acute care services after hospitalization (RTI International analysis of 2014 Medicare claims under contract with the Assistant Secretary for Planning and Evaluation, August 2018 (aea0315)), but a 2020 study that assessed continuity between hospitals and skilled nursing facilities (SNF) found that SNFs received complete mental status information at transition of care only 6% of the time. JAMA Network Open. 2021;4(1):e2033980. doi: 10.1001/jamanetworkopen.2020.33980. This failure to exchange accurate, timely data often leads to inefficient workflows, duplicative data entry, and increased risk of harm attributable to missing or inaccurate information.
The purpose of this IG is to offer a framework that providers and organizations across the spectrum of care can use to exchange observational assessment information. By using this framework to put accessible, usable, and timely data into the hands of providers, patients, and their caregivers, organizations can foster appropriate care for the whole person, promoting their ability to actively engage in daily life at home and in the community and supporting the person in achieving their optimal quality of life. This IG facilitates efforts to build more interoperable health IT systems that support data sharing, first outlined in the landmark Institute of Medicine Report To Err is Human: Building a Safer Health System, and is congruent with current federal efforts (e.g., The Centers for Medicare and Medicaid Services Promoting Interoperability Programs).
The PACIO Project is a collaborative effort to advance interoperable health data exchange between PAC and other providers, patients, their caregivers, and key stakeholders across healthcare and to promote health data exchange in collaboration with policy makers, standards organizations, and industry through a consensus-based approach.
The primary goal of the PACIO Project is to establish the technical foundation for data exchange within PAC and partner organizations across the spectrum of care. It seeks to do so by creating a framework for and community through the development of Fast Healthcare Interoperability Resource (FHIR®) technical implementation guides (IGs) and reference implementations that will facilitate health data exchange through standards-based use case-driven application programming interfaces (APIs).
Information covered in this IG is relevant to providers across the full spectrum of patient care, including acute, sub-acute, long-term post-acute care (LTPAC), community based organizations, and private practice practitioners. The PACIO community brings together healthcare providers with a deep understanding of patient functioning that makes them uniquely suited to author this IG. This understanding comes out of providers’:
The scope of this IG is intentionally broad. It provides a framework within which to represent observations across many aspects of an individual’s functioning and engagement with their environment and the world. To further support the interoperability of systems based on this guide, the IG defines the domains tied to value sets that enumerate terminology codes for related observations. These domains are drawn from the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (commonly known as ICF). ICF was chosen as the source of domains because it takes a holistic view of a person through an interdisciplinary therapy lens, considers how best to support the person’s return to the community, and has been integrated into some EHRs. Examples of ICF categories the IG uses as domains include but are not limited to:
More information on the domains currently defined in this IG, how codes are assigned to the domain-based value sets, and examples drawn from post-acute care assessments required by the IMPACT Act can be found on the Domain Support page. More information on all of the categories that ICF defines can be found in the ICF Browser.
One impetus for this IG is the amendment to the Social Security Act in 2014 to include the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The IMPACT Act requires the standardization and interoperability of patient assessments in specific categories for PAC settings, including long-term care hospitals (LTCHs), home health agencies (HHAs), SNFs, and inpatient rehabilitation facilities (IRFs). It focuses on the standardization of data elements in specified quality measure and patient assessment domains for cross-setting comparison and clinical information exchange, respectively. Functional status, cognitive function and mental status, and impairments are among the clinical domains of required data.
The Act requires:
This IG provides a framework for the exchange of observations relevant to post-acute care and other settings. It seeks to enable exchange of this information and in so doing, to promote its use in clinical care and caregiving. Consistent with this focus, it does not seek to limit or make specific recommendations on either clinical practice itself or the way that software systems display or collect information. Specifically:
This IG is divided into several sections that are listed at the top of each page in the menu bar.
There are no Global profiles defined
Package hl7.fhir.uv.extensions.r4#5.2.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Mon, Feb 10, 2025 21:45+1100+11:00) |
Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00) |
Package hl7.fhir.uv.bulkdata#2.0.0 FHIR based approach for exporting large data sets from a FHIR server to a client application (built Fri, Nov 26, 2021 05:56+1100+11:00) |
Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. |
Package ihe.formatcode.fhir#1.1.0 Implementation Guide for IHE defined FormatCode vocabulary. (built Thu, Feb 24, 2022 16:55-0600-06:00) |
Package hl7.fhir.us.core#6.1.0 The US Core Implementation Guide is based on FHIR Version R4 and defines the minimum conformance requirements for accessing patient data. The Argonaut pilot implementations, ONC 2015 Edition Common Clinical Data Set (CCDS), and ONC U.S. Core Data for Interoperability (USCDI) v1 provided the requirements for this guide. The prior Argonaut search and vocabulary requirements, based on FHIR DSTU2, are updated in this guide to support FHIR Version R4. This guide was used as the basis for further testing and guidance by the Argonaut Project Team to provide additional content and guidance specific to Data Query Access for purpose of ONC Certification testing. These profiles are the foundation for future US Realm FHIR implementation guides. In addition to Argonaut, they are used by DAF-Research, QI-Core, and CIMI. Under the guidance of HL7 and the HL7 US Realm Steering Committee, the content will expand in future versions to meet the needs specific to the US Realm. These requirements were originally developed, balloted, and published in FHIR DSTU2 as part of the Office of the National Coordinator for Health Information Technology (ONC) sponsored Data Access Framework (DAF) project. For more information on how DAF became US Core see the US Core change notes. (built Fri, Jun 30, 2023 14:02+0000+00:00) |
Package hl7.fhir.uv.extensions.r4#5.1.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sat, Apr 27, 2024 18:39+1000+10:00) |
Package hl7.fhir.uv.subscriptions-backport.r4#1.1.0 The Subscription R5 Backport Implementation Guide enables servers running versions of FHIR earlier than R5 to implement a subset of R5 Subscriptions in a standardized way. (built Wed, Jan 11, 2023 15:34+1100+11:00) |
Package hl7.fhir.us.sdoh-clinicalcare#2.2.0 This HL7 Implementation Guide (IG) defines how to exchange Social Determinants of Health (SDOH) content defined by the Gravity Project using the HL7 FHIR standard.. (built Tue, Aug 27, 2024 16:48+0000+00:00) |
This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B} systems. Packages for both R4 (hl7.fhir.us.pacio-pfe.r4) and R4B (hl7.fhir.us.pacio-pfe.r4b) are available.
This publication includes IP covered under the following statements.
IG © 2022+ HL7 International / Patient Care. Package hl7.fhir.us.pacio-pfe#2.0.0 based on FHIR 4.0.1. Generated 2025-07-23
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change
