Person-Centered Outcomes (PCO) Implementation Guide
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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

Related FHIR IGs

Page standards status: Informative

The Person-Centered Outcomes (PCO) IG is complementary and may be used in combination with several other HL7 FHIR Implementation Guides (IGs). The following HL7 FHIR IGs are listed with a brief summary about how this PCO FHIR IG is related to their scope and usage. Each of the following IGs includes a profile for FHIR Goal, often with a specific category code and other Goal element requirements. Other FHIR resource profiles are defined in these IGs that may be used along with PCO IG profiles for expanded use cases in comprehensive care planning.

US Core 6.1.0: All profiles in this version of the PCO FHIR IG are based on US Core 6.1.0 to align with current interoperability requirements in the United States.

  • See the US Core Screening and Assessments guidance page for how this profile represents surveys, screenings, and assessments.
    • Each response to individual questions and each answer to a multi-select or “check all that apply” question is a separate US Core Screening and Assessments Observation. The question is communicated in Observation.code, and the answer is in Observation.value.
    • Multi-question screenings and assessments use the US Core Screening and Assessments Observation to represent a “panel” or grouping. The multi-question surveys or assessments Observation.code is an overarching assessment or screening code, and the Observation.value element SHOULD be empty. Observation.hasMember references US Core Screening and Assessments Observations that represent the responses to each question in the screening or assessment.

US Core 7.0.0: Includes two new profiles that may be relevant for person-centered care planning and could be used in addition to PCO IG profiles without conflict or duplication. The PCO FHIR IG is based on US Core 6.1.0 to align with current adoption in the U.S., but implementers could choose to pre-adopt these new profiles.

SDOH Clinical Care IG: The Social determinants of health (SDOH) Clinical Care IG focuses on representing goals to address an identified social risk or need. The PCO IG is complementary to this since a goal that matters most to a person may fall in an SDOH domain and PCO goals can make use of Gravity terminologies and profile relationships described by the SDOH Clinical Care IG. PCO IG profiles can be applied to enhance progress tracking for SDOH social need goals by using Goal Attainment Scaling (GAS) or a Patient-Reported Outcome Measure (PROM).

US Behavioral Health Profiles Implementation Guide: This IG is designed to facilitate behavioral health integration with other healthcare services, support better clinical decision-making, and improve patient outcomes. The PCO IG is complementary to this IG because a behavioral health goal can make use of PCO IG profiles and GAS Goal extensions to enhance progress tracking and quality measures.

MCC eCare Plan IG: The scope of the PCO FHIR IG is distinct from Multiple Chronic Condition (MCC) eCare Plan IG in that PCO includes more specific profiles and guidance on the use of FHIR resources to support Goal Outcomes and Progress, including optional use of GAS Goal extensions.

eLTSS FHIR IG: The electronic Long-Term Services and Supports (eLTSS) IG focuses on support for packaging eLTSS data in a CarePlan. The PCO IG includes more specific guidance on setting Goal targets using PROM or GAS measures and tracking their progress.

PACIO Personal Functioning and Engagement (PFE) IG: The PFE IG defines how to exchange data related to an individual’s functioning and engagement in daily life, primarily in the context of post-acute and long-term care. The PCO IG focuses on defining the use of Observation profiles in the context of goals that address value-based assessment of what matters most to each person.

PACIO Advance Directive Interoperability (ADI) IG: The ADI IG explains how to represent, exchange, and verify a person’s medical goals, preferences and priorities for medical treatment and interventions regarding future medical care. This scope is complementary to the PCO IG that provides guidance on representing goals that address a value-based assessment of what matters most to a person; this focus often is not medical or related directly to medical treatment and interventions. However, a person-centered care plan may include medical treatment goals, preferences and interventions in a comprehensive care plan. An implementer could choose to integrate PCO FHIR IG profiles in combination with ADI FHIR IG profiles in their applications without validation conflicts.

Physical Activity Implementation Guide: Guidance on how to create and share care plans and goals related to improving a patient's level of physical activity, and how to consistently capture and share the primary, evidence-based measure of a patient's level of physical activity.

  • Goal and CarePlan profiles include a required category code for "PhysicalActivity", and a patient goal for physical activity must support a specified measure code, e.g. "Number of steps in 24 hour Measured". So this is not compatible with a PCO GAS Goal, but could be used to measure progress on person-centered outcomes for a goal barrier.