Additional Guidance

The SDOHCC_Goal_Base_1 profile allows the representation of Goals that address SDOH Conditions.

Many of the resources/profiles used for SDOH reference one another. The current flow is that QuestionnaireResponses result in Observations that are used as evidence for Conditions that are addressed by Goals that lead to ServiceRequests and Procedures.

The diagram below shows a simple example of a relationship between Observation, Condition and Goal. An initial Observation (1) is evidence for a Condition (2) that is addressed by a Goal (3) that may have an outcome of a later Observation (4).

The sections that follow provide additional guidance on some elements in the SDOHCC_Goal_Base_1 profile.

Goal.category

Goal.category is optional and bound to the FHIR "Goal category" value set with binding strength: Example.

Additionally, an optional Goal.category slice bound to the "SDOHCC ValueSet SDOHDomain 1" value set allows the categorization of a Goal into one or more of the SDOH domains (e.g., food-insecurity-domain, inadequate-housing-domain, etc.). It is recommended that this optional slice be used in order to facilitate searching for SDOH goals.

Goal.description

Goal.description is currently bound to codes from the FHIR "LOINC Codes" value set with binding strength: Extensible. As the Gravity Project continues to refine content for the SDOH domains (e.g., food, housing, transportation, etc.), Gravity intends to work with LOINC to include Goal.description codes that pertain to SDOH domains.

Goal.subject

Since this profile is based on the US Core Goal Profile, Goal.subject is restricted to referencing US Core Patient Profile.

Goal.target

Goal.target can be used to "Indicate what should be done by when."

Exactly how Goal.target.will be used for SDOH goals is evolving. The following is general guidance for Goal.target.

Goal.target.measure

Goal.target.measure is currently bound to codes from the FHIR "LOINC Codes" value set with binding strength: Extensible. Gravity intends to work with LOINC to include Goal.target.measure codes that pertain to SDOH domains.

For SDOH goals that have only one target measure that aligns exactly with the goal description, current guidance is to use the same code for Goal.target.measure as for Goal.description. This approach allows the use of Goal.target.due[x] to specify the date the goal should be achieved by. This approach is proposed because it is not possible to assign a due date to a Goal.description without using Goal.target.

Goal.statusDate

The Goal Resource does not clearly specify whether Goal.statusDate applies to Goal.achievementStatus or to Goal.lifecycleStatus. It is recommended that Goal.statusDate be synchronized with Goal.achievementStatus.

Goal.addresses

Goal.addresses is sliced to allow the preferred option of referencing the SDOHCC_Condition_Base_1 Profile and/or SDOHCC_Observation_ScreeningResponseBase_1 Profile.

Goal.addresses should reference the SDOHCC_Condition_Base_1 Profile and/or SDOHCC_Observation_ScreeningResponseBase_1 Profile if they exist.

Additionally, Goal.addresses may reference Condition, Observation and/or RiskAssessment.

Goal.outcomeCode

Goal.outcome.Code can be used identify a goal's outcome when Goal.status is assessed. Goal.outcomeCode is currently bound to the FHIR "LOINC Codes" value set with binding strength: Example. Gravity intends to work with LOINC to include Goal.outcome codes that pertain to SDOH domains.

Of note, information represented by Goal.outcomeCode overlaps significantly with information represented by Goal.outcomeReference. Multiple approaches to representing the same information may negatively impact interoperability. Therefore, where there is overlap in information provided by Goal.outcomeCode and Goal.outcomeReference, it is recommended that Goal.outcomeReference should be used to identify/provide details of goal outcomes.

Goal.outcomeReference

Goal.outcomeReference can be used to provide details of the Goal outcome (presumably when Goal.status is assessed). Goal.achievementStatus may be supported by an update to Goal.outcomeReference. The base FHIR Resource restricts Goal.outcomeReference to referencing only Observations.

Goal.outcomeReference may reference any Observation that supports the Goal status.

Additionally, Goal.outcomeReference is sliced to allow referencing the Observation_ScreeningResponseBase_1 Profile if it exists and is applicable.

Where there is significant overlap in information provided by Goal.outcomeCode and Goal.outcomeReference, it is recommended that Goal.outcomeReference be used to identify/provide details of goal outcomes.

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
achievementStatus	S	1..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
category		0..*	(Slice Definition)	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOHDomain	S	0..*	CodeableConcept	e.g., food-insecurity-domain | transportation-insecurity-domain Binding: SDOHCC ValueSet SDOHDomain 1 (required)
description		1..1	CodeableConcept	Code or text describing goal Binding: LOINCCodes (extensible)
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (extensible)
addresses		0..*	(Slice Definition)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition Base 1 | SDOHCC Observation ScreeningResponseBase 1)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: LOINCCodes (example)
outcomeReference		0..*	(Slice Definition)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation ScreeningResponseBase 1)	Observation that resulted from goal
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	1..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
category	Σ	0..*	(Slice Definition)	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOHDomain	SΣ	0..*	CodeableConcept	e.g., food-insecurity-domain | transportation-insecurity-domain Binding: SDOHCC ValueSet SDOHDomain 1 (required)
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: LOINCCodes (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SI	0..*	BackboneElement	Target outcome for the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣI	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (extensible)
detail[x]	ΣI	0..1		The target value to be achieved Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detailQuantity			Quantity
detailRange			Range
detailCodeableConcept			CodeableConcept
detailString			string
detailBoolean			boolean
detailInteger			integer
detailRatio			Ratio
due[x]	Σ	0..1	(Slice Definition)	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses		0..*	(Slice Definition)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition Base 1 | SDOHCC Observation ScreeningResponseBase 1)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: LOINCCodes (example)
outcomeReference		0..*	(Slice Definition)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation ScreeningResponseBase 1)	Observation that resulted from goal
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
lifecycleStatus	?!Σ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	Σ	1..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
category:SDOHDomain	Σ	0..*	CodeableConcept	e.g., food-insecurity-domain | transportation-insecurity-domain Binding: SDOHCC ValueSet SDOHDomain 1 (required)
description	Σ	1..1	CodeableConcept	Code or text describing goal Binding: LOINCCodes (extensible)
subject	Σ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
target	I	0..*	BackboneElement	Target outcome for the goal
due[x]:dueDate	Σ	0..1	date	Reach goal on or before
addresses:SupportedAddresses		0..*	Reference(SDOHCC Condition Base 1 | SDOHCC Observation ScreeningResponseBase 1)	Issues addressed by this goal
outcomeReference:SupportedOutcomeReference		0..*	Reference(SDOHCC Observation ScreeningResponseBase 1)	Observation that resulted from goal
Documentation for this format

This structure is derived from USCoreGoalProfile

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

• http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-Condition-Base-1
• http://hl7.org/fhir/us/sdoh-clinicalcare/StructureDefinition/SDOHCC-Observation-ScreeningResponseBase-1

Slices

This structure defines the following Slices:

• The element Goal.category is sliced based on the value of value:$this
• The element Goal.addresses is sliced based on the value of profile:resolve()
• The element Goal.outcomeReference is sliced based on the value of profile:resolve()

Differential View

This structure is derived from USCoreGoalProfile

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
achievementStatus	S	1..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
category		0..*	(Slice Definition)	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this
category:SDOHDomain	S	0..*	CodeableConcept	e.g., food-insecurity-domain | transportation-insecurity-domain Binding: SDOHCC ValueSet SDOHDomain 1 (required)
description		1..1	CodeableConcept	Code or text describing goal Binding: LOINCCodes (extensible)
target
measure		0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (extensible)
addresses		0..*	(Slice Definition)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition Base 1 | SDOHCC Observation ScreeningResponseBase 1)	Issues addressed by this goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: LOINCCodes (example)
outcomeReference		0..*	(Slice Definition)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation ScreeningResponseBase 1)	Observation that resulted from goal
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Goal		0..*	USCoreGoalProfile	Describes the intended objective(s) for a patient, group or organization
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	External Ids for this goal
lifecycleStatus	?!SΣ	1..1	code	proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected Binding: GoalLifecycleStatus (required)
achievementStatus	SΣ	1..1	CodeableConcept	in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable Binding: GoalAchievementStatus (preferred): Indicates the progression, or lack thereof, towards the goal against the target.
category	Σ	0..*	(Slice Definition)	E.g. Treatment, dietary, behavioral, etc. Slice: Unordered, Open by value:$this Binding: GoalCategory (example): Codes for grouping and sorting goals.
category:SDOHDomain	SΣ	0..*	CodeableConcept	e.g., food-insecurity-domain | transportation-insecurity-domain Binding: SDOHCC ValueSet SDOHDomain 1 (required)
priority	Σ	0..1	CodeableConcept	high-priority | medium-priority | low-priority Binding: GoalPriority (preferred): The level of importance associated with a goal.
description	SΣ	1..1	CodeableConcept	Code or text describing goal Binding: LOINCCodes (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who this goal is intended for
start[x]	Σ	0..1		When goal pursuit begins Binding: GoalStartEvent (example): Codes describing events that can trigger the initiation of a goal.
startDate			date
startCodeableConcept			CodeableConcept
target	SI	0..*	BackboneElement	Target outcome for the goal
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
measure	ΣI	0..1	CodeableConcept	The parameter whose value is being tracked Binding: LOINCCodes (extensible)
detail[x]	ΣI	0..1		The target value to be achieved Binding: (unbound) (example): Codes to identify the target value of the focus to be achieved to signify the fulfillment of the goal.
detailQuantity			Quantity
detailRange			Range
detailCodeableConcept			CodeableConcept
detailString			string
detailBoolean			boolean
detailInteger			integer
detailRatio			Ratio
due[x]	Σ	0..1	(Slice Definition)	Reach goal on or before Slice: Unordered, Closed by type:$this
due[x]:dueDate	SΣ	0..1	date	Reach goal on or before
statusDate	Σ	0..1	date	When goal status took effect
statusReason		0..1	string	Reason for current status
expressedBy	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)	Who's responsible for creating Goal?
addresses		0..*	(Slice Definition)	Issues addressed by this goal Slice: Unordered, Open by profile:resolve()
addresses:SupportedAddresses	S	0..*	Reference(SDOHCC Condition Base 1 | SDOHCC Observation ScreeningResponseBase 1)	Issues addressed by this goal
note		0..*	Annotation	Comments about the goal
outcomeCode		0..*	CodeableConcept	What result was achieved regarding the goal? Binding: LOINCCodes (example)
outcomeReference		0..*	(Slice Definition)	Observation that resulted from goal Slice: Unordered, Open by profile:resolve()
outcomeReference:SupportedOutcomeReference	S	0..*	Reference(SDOHCC Observation ScreeningResponseBase 1)	Observation that resulted from goal
Documentation for this format