Person-Centered Outcomes (PCO) Implementation Guide
1.0.0-ballot - STU 1 Ballot United States of America flag

This page is part of the Person-Centered Outcomes (PCO) Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Library: GoalFollowUpMeasure

Official URL: http://hl7.org/fhir/us/pco/Library/GoalFollowUpMeasure Version: 1.0.0-ballot
Standards status: Draft Maturity Level: 2 Computable Name: GoalFollowUpMeasure

CQL logic for the Goal Follow-up Measure

Id: GoalFollowUpMeasure
Version: 1.0.0-ballot
Url: GoalFollowUpMeasure
Status: draft
Type:

system: http://terminology.hl7.org/CodeSystem/library-type

code: logic-library

Date: 2025-03-28 21:02:54+0000
Publisher: HL7 International / Patient Care
Description:

CQL logic for the Goal Follow-up Measure
Jurisdiction: US
Related Artifacts:

Dependencies
Parameters:
NameTypeMinMaxIn/Out
Measurement PeriodPeriod01In
Follow-Up IntervalRange01In
PatientPatient01Out
Initial PopulationPatient0*Out
DenominatorPatient0*Out
Denominator ExclusionsResource01Out
Denominator ExceptionsResource01Out
NumeratorPatient0*Out
Data Requirements:
TypeProfileMSCode Filter
Patient http://hl7.org/fhir/StructureDefinition/Patient
Observation http://hl7.org/fhir/StructureDefinition/Observation ;;;
Observation http://hl7.org/fhir/StructureDefinition/Observation ; code filter:
path: code
value set: http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score
Observation http://hl7.org/fhir/StructureDefinition/Observation ; code filter:
path: code
value set: http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures
Goal http://hl7.org/fhir/StructureDefinition/Goal ;;;;;
CarePlan http://hl7.org/fhir/StructureDefinition/CarePlan ;
Content: text/cql
/*
@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.

@author: Mountain Lotus WellBeing LLC
*/
library GoalFollowUpMeasure version '0.1.0'

using FHIR version '4.0.1'

include FHIRHelpers version '4.4.000' called FHIRHelpers
include PCOCommon version '0.1.0' called PC
include GoalAttainmentLogic version '0.1.0' called PCOLogic

parameter "Measurement Period" Interval<DateTime>
    default Interval[@2024-01-01T00:00:00.000Z, @2024-12-31T23:59:59.999Z]

parameter "Follow-Up Interval" Interval<System.Quantity>
  default Interval[2 weeks, 26 weeks]

context Patient

/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
  Patient person
    where AgeInYearsAt(start of "Measurement Period") >= 18
}

/*
@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"

define "Denominator Exclusions":
  null

define "Denominator Exceptions":
  null

/*
@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"
Content: application/elm+xml
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Content: application/elm+json
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