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Resource Measure/FHIR Server from package hl7.fhir.us.pco#current (171 ms)

Package hl7.fhir.us.pco
Type Measure
Id Id
FHIR Version R4
Source http://hl7.org/fhir/us/pco/https://build.fhir.org/ig/mtnlotus/pco-ig/Measure-GoalFollowUpMeasure.html
Url http://hl7.org/fhir/us/pco/Measure/GoalFollowUpMeasure
Version 0.2.0
Status active
Date 2024-12-11T00:23:37+00:00
Name GoalFollowUpMeasure
Title Person-Centered Goal Follow-Up
Experimental False
Realm us
Authority hl7
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.
Purpose 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.
Copyright Measure definition is copyright 2024 by NCQA. LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

Resources that use this resource

No resources found

Resources that this resource uses

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Narrative

Note: links and images are rebased to the (stated) source

Knowledge Artifact Metadata
Name (machine-readable) GoalFollowUpMeasure
Title (human-readable) Person-Centered Goal Follow-Up
Status Active
Experimental false
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.
Purpose

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.
Clinical Usage Content TBD.
Effective Period 2024-01-01..2024-12-31
Measure Developer HL7 International / Patient Care: http://www.hl7.org/Special/committees/patientcare
Measure Steward HL7 International / Patient Care
Steward Contact Details HL7 International / Patient Care: http://www.hl7.org/Special/committees/patientcare,patientcare@lists.HL7.org
Copyright

Measure definition is copyright 2024 by NCQA.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.
Measure Metadata
Short Name Identifier PCOMeasure1
Version Independent Identifier urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328
Version Specific Identifier urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05
Publisher (CMS) Identifier NA
Version Number 0.2.0
Measure Scoring Proportion
Rationale

Goal-directed care in healthcare centers on setting and achieving specific, personalized goals that prioritize an individual's well-being and "What Matters Most" to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify individual goals related to health outcomes, functional improvement, or symptom management. Once goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness.
Clinical Recommendation Statement

None at this time.
Measure Population Criteria (ID: 64f0d91d56d636294b157d97)
Summary Content TBD
Initial Population ID: 692C6F6B-4153-496F-8582-0839A0816567
Description:

Individuals 18 years of age and older.

Logic Definition: Initial Population
Denominator ID: 3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9
Description:

Individuals 18 years of age and older with a complex care need and has a PCO Goal.

Logic Definition: Denominator
Denominator Exclusion ID: AA76FF0E-0EF9-40E6-9913-90FA63D50298
Description:

None

Logic Definition: Denominator Exclusions
Numerator ID: 3D2BED97-5ADC-4210-8A3E-91B13652E7D0
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.

Logic Definition: Numerator
Denominator Exception ID: 4511743B-B054-4A08-800B-C4624450C38C
Description:

None

Logic Definition: Denominator Exceptions
Population Basis Patient
Type Process
Rate Aggregation None
Improvement Notation Increased score indicates improvement
Measure Logic
Primary Library GoalFollowUpMeasure
Dependency Description: Library PCOLogic
Resource: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0
Canonical URL: http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0
Dependency Description: Library FHIRHelpers
Resource: http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000
Canonical URL: http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000
Dependency Description: Library PC
Resource: http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0
Canonical URL: http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0
Dependency Description: Code system LOINC
Resource: Logical Observation Identifiers, Names and Codes (LOINC)
Canonical URL: http://loinc.org
Dependency Description: Value set PCO Categories
Resource: http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset
Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset
Dependency Description: Value set Goal Attainment Scaling (GAS) Score
Resource: Goal Attainment Scaling (GAS) Score
Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score
Dependency Description: Value set PROM Target Measures
Resource: PROM Target Measures
Canonical URL: http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures
Direct Reference Code Display: Goal attainment scale
Code: 68489
System: http://loinc.org
Parameter Name: Measurement Period
Use: In
Min Cardinality: 0
Max Cardinality: 1
Type: Period
Parameter Name: Follow-Up Interval
Use: In
Min Cardinality: 0
Max Cardinality: 1
Type: Range
Parameter Name: Numerator
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Patient
Parameter Name: Denominator
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Patient
Parameter Name: Initial Population
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Patient
Parameter Name: Denominator Exclusions
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: Resource
Parameter Name: Denominator Exceptions
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: Resource
Measure Logic Data Requirements
Data Requirement Type: Patient
Profile(s): Patient
Data Requirement Type: Goal
Profile(s): Goal
Must Support Elements: category, start, measure, id
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: Goal Attainment Scaling (GAS) Score
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: PROM Target Measures
Data Requirement Type: CarePlan
Profile(s): CarePlan
Must Support Elements: goal
Measure Logic Definitions
Logic Definition Library Name: GoalFollowUpMeasure 
/*
@description: Includes individuals 18 years of age and older.
*/
define "Initial Population": {
  Patient person
    where AgeInYearsAt(start of "Measurement Period") >= 18
}
Logic Definition Library Name: GoalFollowUpMeasure 
/*
@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"
Logic Definition Library Name: GoalAttainmentLogic 
/* 
  A "PCO Goal" is any FHIR Goal that has a category in "PCO Categories"
  and has a start date.
  TODO: or a Goal that addresses a What Matters observation.
*/
define "PCO Goals":
  [Goal] goal
    where goal.category in "PCO Categories"
      and (goal.start as FHIR.date) is not null
Logic Definition Library Name: GoalAttainmentLogic 
// Observations containing a GAS score.
define "GAS Scores":
  [Observation: "Goal Attainment Scaling (GAS) Score"]
Logic Definition Library Name: GoalAttainmentLogic 
// PCO Goals whose startDate falls within the Measurement Period
define "PCO Goals During Measurement Period":
  "PCO Goals" goal
    where (ToDateTime(goal.start as FHIR.date) during "Measurement Period")
      and (goal.hasGAS() or goal.hasPROM())
      and exists goal.carePlans()
Logic Definition Library Name: GoalAttainmentLogic 
// Observations containing a PROM score.
define "PROM Scores":
  [Observation: "PROM Target Measures"]
Logic Definition Library Name: GoalAttainmentLogic 
/* 
Follow-Up Scares are PCO score observations taken during the Measurement Period,
and during the follow-up period for its Goal. Default follow-up period is 
2 weeks to 6 months following the goal startDate.
*/
define "Follow-Up Scores During Measurement Period":
  flatten( "PCO Goals During Measurement Period" goal
    let pcoScores: goal.pcoScores()
      return pcoScores score 
        let scoreDate: score.effective as FHIR.dateTime
        where scoreDate during "Measurement Period"
          and scoreDate during "Follow-Up Interval For"(goal)
  )
Logic Definition Library Name: GoalFollowUpMeasure 
/*
@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"
Logic Definition Library Name: GoalFollowUpMeasure 
define "Denominator Exclusions":
  null
Logic Definition Library Name: GoalFollowUpMeasure 
define "Denominator Exceptions":
  null
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }
Logic Definition Library Name: FHIRHelpers 
define function ToDate(value date): value.value
Logic Definition Library Name: GoalAttainmentLogic 
// where exists obs.performer.resolveRelatedPersons()

define fluent function hasGAS(goal Goal):
  exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling')
    or exists (goal.target target
      where target.measure = "Goal attainment scale"
    )
    or exists goal.gasScores()
Logic Definition Library Name: PCOCommon 
/*
@description: Returns any extensions defined on the given resource with the specified url.
@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define fluent function extensions(domainResource DomainResource, url String):
  domainResource.extension E
	  where E.url = url
		return E
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Logic Definition Library Name: GoalAttainmentLogic 
// Returns a list of Observation including only GAS scores
define fluent function gasScores(goal Goal):
  "GAS Scores" score
    where score.focusGoals() contains goal
Logic Definition Library Name: GoalAttainmentLogic 
// Returns a list of Goal where focus includes the given Observation.
define fluent function focusGoals(obs Observation):
  obs.focus.resolveGoals()
Logic Definition Library Name: PCOCommon 
define fluent function resolveGoals(references List<Reference>):
  flatten( references ref
    return [Goal] resource
      where resource.id = ref.reference.getId()
  )
Logic Definition Library Name: PCOCommon 
define fluent function getId(uri String):
  Last(Split(uri, '/'))
Logic Definition Library Name: GoalAttainmentLogic 
/// Returns true if this Goal has a PROM code in its target.measure
define fluent function hasPROM(goal Goal):
  exists (goal.target target
    where target.measure in "PROM Target Measures"
  )
Logic Definition Library Name: PCOCommon 
// Returns a list of CarePlan that support this Goal.
define fluent function carePlans(goal Goal):
  [CarePlan] carePlan
    where exists ( carePlan.goal goalRef
        where goal.id = goalRef.reference.getId()
    )
Logic Definition Library Name: GoalAttainmentLogic 
// Returns a list of Observation including both GAS and PROM scores
define fluent function pcoScores(goal Goal):
  goal.gasScores()
    union goal.promScores()
Logic Definition Library Name: GoalAttainmentLogic 
// Returns a list of Observation including only PROM scores
define fluent function promScores(goal Goal):
  "PROM Scores" score
    where score.focusGoals() contains goal
Logic Definition Library Name: FHIRHelpers 
define function ToDateTime(value dateTime): value.value
Logic Definition Library Name: GoalAttainmentLogic 
/*
Computes the follow-up interval for a Goal based on this measure's "Follow-Up Interval" parameter.
@return Interval<DateTime>
*/
define function "Follow-Up Interval For" (goal Goal):
  goal goal
    let startDate: ToDateTime(goal.start as FHIR.date)
      return Interval(startDate + start of "Follow-Up Interval", startDate + end of "Follow-Up Interval")
Generated using version 0.4.6 of the sample-content-ig Liquid templates

Source

{
  "resourceType" : "Measure",
  "id" : "GoalFollowUpMeasure",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm"
    ]
  },
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n  <table class=\"narrative-table\">\n    <tbody>\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Knowledge Artifact Metadata</th>\n\n</tr>\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Name (machine-readable)</th>\n\n<td class=\"content-container\">GoalFollowUpMeasure</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Title (human-readable)</th>\n\n<td class=\"content-container\">Person-Centered Goal Follow-Up</td>\n</tr>\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Status</th>\n\n<td class=\"content-container\">Active</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Experimental</th>\n\n<td class=\"content-container\">false</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Description</th>\n\n<td class=\"content-container\"><div><p>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.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Purpose</th>\n\n<td class=\"content-container\"><div><p>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.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Clinical Usage</th>\n\n<td class=\"content-container\">Content TBD.</td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Effective Period</th>\n\n<td class=\"content-container\">2024-01-01..2024-12-31</td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Developer</th>\n\n<td class=\"content-container\">HL7 International / Patient Care: <a href=\"http://www.hl7.org/Special/committees/patientcare\">http://www.hl7.org/Special/committees/patientcare</a></td>\n</tr>\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Steward</th>\n\n<td class=\"content-container\">HL7 International / Patient Care</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Steward Contact Details</th>\n\n<td class=\"content-container\">HL7 International / Patient Care: <a href=\"http://www.hl7.org/Special/committees/patientcare\">http://www.hl7.org/Special/committees/patientcare</a>,<a href=\"mailto:patientcare@lists.HL7.org\">patientcare@lists.HL7.org</a></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Copyright</th>\n\n<td class=\"content-container\"><div><p>Measure definition is copyright 2024 by NCQA.</p>\n<p>LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.</p>\n</div></td>\n</tr>\n\n\n\n\n\n\n\n\n\n\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Metadata</th>\n\n</tr>\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Short Name Identifier</th>\n\n<td class=\"content-container\">PCOMeasure1</td>\n</tr>\n\n\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Independent Identifier</th>\n\n<td class=\"content-container\">urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328</td>\n</tr>\n\n\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Specific Identifier</th>\n\n<td class=\"content-container\">urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05</td>\n</tr>\n\n\n\n  \n    \n    \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Publisher (CMS) Identifier</th>\n\n<td class=\"content-container\">NA</td>\n</tr>\n\n  \n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Version Number</th>\n\n<td class=\"content-container\">0.2.0</td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Measure Scoring</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-scoring proportion}\">Proportion</span></td>\n</tr>\n\n\n\n\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Rationale</th>\n\n<td class=\"content-container\"><div><p>Goal-directed care in healthcare centers on setting and achieving specific, personalized goals that prioritize an individual's well-being and &quot;What Matters Most&quot; to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify individual goals related to health outcomes, functional improvement, or symptom management. Once goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness.</p>\n</div></td>\n</tr>\n\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Clinical Recommendation Statement</th>\n\n<td class=\"content-container\"><div><p>None at this time.</p>\n</div></td>\n</tr>\n\n\n\n\n\n\n\n\n\n  \n    \n    <tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Population Criteria (ID: 64f0d91d56d636294b157d97)</th>\n\n</tr>\n  \n  \n    \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Summary</th>\n\n<td class=\"content-container\">Content TBD</td>\n</tr>\n\n  \n  \n  \n    <tr>\n      \n        \n<th scope=\"row\" class=\"row-header\">Initial Population</th>\n\n      \n      <td class=\"content-container\">\n        \n        <em>ID</em>: 692C6F6B-4153-496F-8582-0839A0816567\n        <br/>\n        \n        \n          <em>Description</em>:\n          <p style=\"white-space: pre-line\" class=\"tab-one\">Individuals 18 years of age and older.</p>\n        \n        \n          \n            \n            <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-initial-population\">Initial Population</a> \n          \n        \n      </td>\n    </tr>\n  \n\n  \n    <tr>\n      \n        \n<th scope=\"row\" class=\"row-header\">Denominator</th>\n\n      \n      <td class=\"content-container\">\n        \n        <em>ID</em>: 3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9\n        <br/>\n        \n        \n          <em>Description</em>:\n          <p style=\"white-space: pre-line\" class=\"tab-one\">Individuals 18 years of age and older with a complex care need and has a PCO Goal.</p>\n        \n        \n          \n            \n            <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator\">Denominator</a> \n          \n        \n      </td>\n    </tr>\n  \n\n  \n    <tr>\n      \n        \n<th scope=\"row\" class=\"row-header\">Denominator Exclusion</th>\n\n      \n      <td class=\"content-container\">\n        \n        <em>ID</em>: AA76FF0E-0EF9-40E6-9913-90FA63D50298\n        <br/>\n        \n        \n          <em>Description</em>:\n          <p style=\"white-space: pre-line\" class=\"tab-one\">None</p>\n        \n        \n          \n            \n            <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator-exclusions\">Denominator Exclusions</a> \n          \n        \n      </td>\n    </tr>\n  \n\n  \n    <tr>\n      \n        \n<th scope=\"row\" class=\"row-header\">Numerator</th>\n\n      \n      <td class=\"content-container\">\n        \n        <em>ID</em>: 3D2BED97-5ADC-4210-8A3E-91B13652E7D0\n        <br/>\n        \n        \n          <em>Description</em>:\n          <p style=\"white-space: pre-line\" class=\"tab-one\">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.</p>\n        \n        \n          \n            \n            <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-numerator\">Numerator</a> \n          \n        \n      </td>\n    </tr>\n  \n\n  \n    <tr>\n      \n        \n<th scope=\"row\" class=\"row-header\">Denominator Exception</th>\n\n      \n      <td class=\"content-container\">\n        \n        <em>ID</em>: 4511743B-B054-4A08-800B-C4624450C38C\n        <br/>\n        \n        \n          <em>Description</em>:\n          <p style=\"white-space: pre-line\" class=\"tab-one\">None</p>\n        \n        \n          \n            \n            <em>Logic Definition</em>: <a href=\"#goalfollowupmeasure-denominator-exceptions\">Denominator Exceptions</a> \n          \n        \n      </td>\n    </tr>\n  \n\n  \n  \n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Population Basis</th>\n\n<td class=\"content-container\">Patient</td>\n</tr>\n\n\n\n\n\n\n\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Type</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-type process}\">Process</span></td>\n</tr>\n\n\n\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Rate Aggregation</th>\n\n<td class=\"content-container\">None</td>\n</tr>\n\n\n\n  \n<tr>\n\n<th scope=\"row\" class=\"row-header\">Improvement Notation</th>\n\n<td class=\"content-container\"><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-improvement-notation increase}\">Increased score indicates improvement</span></td>\n</tr>\n\n\n\n\n\n\n<tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Logic</th>\n\n</tr>\n\n<tr>\n\n<th scope=\"row\" class=\"row-header\">Primary Library</th>\n\n<td class=\"content-container\"><a href=\"Library-GoalFollowUpMeasure.html\">GoalFollowUpMeasure</a></td>\n</tr>\n\n\n\n\n  \n  \n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Library PCOLogic\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0</code>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Library FHIRHelpers\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000</code>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Library PC\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0</code>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Code system LOINC\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"http://terminology.hl7.org/5.2.0/CodeSystem-v3-loinc.html\">Logical Observation Identifiers, Names and Codes (LOINC)</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://loinc.org</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Value set PCO Categories\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <code>http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset</code>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Value set Goal Attainment Scaling (GAS) Score\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score</tt>\n    \n  </td>\n</tr>\n\n<tr>\n  \n  \n  \n  \n  \n<th scope=\"row\" class=\"row-header\">Dependency</th>\n\n  \n  <td class=\"content-container\">\n    \n    <em>Description</em>: Value set PROM Target Measures\n    \n    <br/>\n    \n    \n    \n    \n    \n    \n    <em>Resource</em>: <a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a>\n    <br/>\n    <em>Canonical URL</em>: <tt>http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures</tt>\n    \n  </td>\n</tr>\n\n\n  \n  <tr>\n    <th scope=\"row\" class=\"row-header\">Direct Reference Code</th>\n    <td class=\"content-container\">\n      \n        <em>Display</em>: Goal attainment scale\n        <br/>\n      \n      <em>Code</em>: 68489\n      <br/>\n      <em>System</em>: <tt>http://loinc.org</tt>\n    </td>\n  </tr>\n\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Measurement Period\n    <br/>\n    <em>Use</em>: In\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: 1\n    <br/>\n    <em>Type</em>: Period\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Follow-Up Interval\n    <br/>\n    <em>Use</em>: In\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: 1\n    <br/>\n    <em>Type</em>: Range\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Numerator\n    <br/>\n    <em>Use</em>: Out\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: *\n    <br/>\n    <em>Type</em>: Patient\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Denominator\n    <br/>\n    <em>Use</em>: Out\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: *\n    <br/>\n    <em>Type</em>: Patient\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Initial Population\n    <br/>\n    <em>Use</em>: Out\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: *\n    <br/>\n    <em>Type</em>: Patient\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Denominator Exclusions\n    <br/>\n    <em>Use</em>: Out\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: 1\n    <br/>\n    <em>Type</em>: Resource\n  </td>\n</tr>\n  \n  <tr>\n  \n<th scope=\"row\" class=\"row-header\">Parameter</th>\n\n  <td class=\"content-container\">\n    <em>Name</em>: Denominator Exceptions\n    <br/>\n    <em>Use</em>: Out\n    <br/>\n    <em>Min Cardinality</em>: 0\n    <br/>\n    <em>Max Cardinality</em>: 1\n    <br/>\n    <em>Type</em>: Resource\n  </td>\n</tr>\n  \n  \n  <tr>\n    <th colspan=\"2\" scope=\"row\" class=\"section-header\"><a name=\"effective-data-requirements\"> </a>Measure Logic Data Requirements</th>\n  </tr>\n  \n  \n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: Patient\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/R4/patient.html\">Patient</a>\n    <br/>        \n  \n   \n   \n   \n  </td>\n</tr>\n\n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: Goal\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/R4/goal.html\">Goal</a>\n    <br/>        \n  \n   \n   \n    <em>Must Support Elements</em>: category, start, measure, id\n    <br/>\n   \n   \n  </td>\n</tr>\n\n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: Observation\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>\n    <br/>        \n  \n   \n   \n    <em>Must Support Elements</em>: code\n    <br/>\n   \n  \n    <em>Code Filter(s)</em>: \n    <br/>\n  \n  \n    <span class=\"tab-one\"><em>Path</em>: code</span>\n    <br/>\n  \n  \n  \n    <span class=\"tab-one\"><em>ValueSet</em>:</span> <a href=\"ValueSet-goal-attainment-scaling-score.html\">Goal Attainment Scaling (GAS) Score</a>\n    <br/> \n  \n  \n  \n   \n  </td>\n</tr>\n\n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: Observation\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/R4/observation.html\">Observation</a>\n    <br/>        \n  \n   \n   \n    <em>Must Support Elements</em>: code\n    <br/>\n   \n  \n    <em>Code Filter(s)</em>: \n    <br/>\n  \n  \n    <span class=\"tab-one\"><em>Path</em>: code</span>\n    <br/>\n  \n  \n  \n    <span class=\"tab-one\"><em>ValueSet</em>:</span> <a href=\"ValueSet-prom-target-measures.html\">PROM Target Measures</a>\n    <br/> \n  \n  \n  \n   \n  </td>\n</tr>\n\n<tr>\n  <th scope=\"row\" class=\"row-header\">Data Requirement</th>\n  <td class=\"content-container\">\n    <em>Type</em>: CarePlan\n    <br/>\n  \n    <em>Profile(s)</em>: \n  \n    <a href=\"http://hl7.org/fhir/R4/careplan.html\">CarePlan</a>\n    <br/>        \n  \n   \n   \n    <em>Must Support Elements</em>: goal\n    <br/>\n   \n   \n  </td>\n</tr>\n\n  \n  <tr>\n\n<th colspan=\"2\" scope=\"row\" class=\"row-header\">Measure Logic Definitions</th>\n\n</tr>\n  \n          \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalfollowupmeasure-initial-population\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Includes individuals 18 years of age and older.\n*/\ndefine &quot;Initial Population&quot;: {\n  Patient person\n    where AgeInYearsAt(start of &quot;Measurement Period&quot;) &gt;= 18\n}</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalfollowupmeasure-denominator\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Initial Population individuals with a complex care need and has a PCO Goal.\n@comment: TODO - How do we determine &quot;complex care need?&quot;\n*/\ndefine &quot;Denominator&quot;:\n  &quot;Initial Population&quot;</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-pco-goals\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/* \n  A &quot;PCO Goal&quot; is any FHIR Goal that has a category in &quot;PCO Categories&quot;\n  and has a start date.\n  TODO: or a Goal that addresses a What Matters observation.\n*/\ndefine &quot;PCO Goals&quot;:\n  [Goal] goal\n    where goal.category in &quot;PCO Categories&quot;\n      and (goal.start as FHIR.date) is not null</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-gas-scores\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Observations containing a GAS score.\ndefine &quot;GAS Scores&quot;:\n  [Observation: &quot;Goal Attainment Scaling (GAS) Score&quot;]</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-pco-goals-during-measurement-period\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// PCO Goals whose startDate falls within the Measurement Period\ndefine &quot;PCO Goals During Measurement Period&quot;:\n  &quot;PCO Goals&quot; goal\n    where (ToDateTime(goal.start as FHIR.date) during &quot;Measurement Period&quot;)\n      and (goal.hasGAS() or goal.hasPROM())\n      and exists goal.carePlans()</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-prom-scores\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Observations containing a PROM score.\ndefine &quot;PROM Scores&quot;:\n  [Observation: &quot;PROM Target Measures&quot;]</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-follow-up-scores-during-measurement-period\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/* \nFollow-Up Scares are PCO score observations taken during the Measurement Period,\nand during the follow-up period for its Goal. Default follow-up period is \n2 weeks to 6 months following the goal startDate.\n*/\ndefine &quot;Follow-Up Scores During Measurement Period&quot;:\n  flatten( &quot;PCO Goals During Measurement Period&quot; goal\n    let pcoScores: goal.pcoScores()\n      return pcoScores score \n        let scoreDate: score.effective as FHIR.dateTime\n        where scoreDate during &quot;Measurement Period&quot;\n          and scoreDate during &quot;Follow-Up Interval For&quot;(goal)\n  )</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalfollowupmeasure-numerator\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Indivuals who received follow-up on their PCO goal within two\nweeks to six months of when the PCO goal and GAS or PROM were identified.\n*/\ndefine &quot;Numerator&quot;:\n  &quot;Denominator&quot; person\n    where exists PCOLogic.&quot;Follow-Up Scores During Measurement Period&quot;</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalfollowupmeasure-denominator-exclusions\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define &quot;Denominator Exclusions&quot;:\n  null</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalfollowupmeasure-denominator-exceptions\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalFollowUpMeasure</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define &quot;Denominator Exceptions&quot;:\n  null</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"fhirhelpers-toconcept\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n    if concept is null then\n        null\n    else\n        System.Concept {\n            codes: concept.coding C return ToCode(C),\n            display: concept.text.value\n        }</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"fhirhelpers-todate\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToDate(value date): value.value</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-hasgas\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// where exists obs.performer.resolveRelatedPersons()\n\ndefine fluent function hasGAS(goal Goal):\n  exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling')\n    or exists (goal.target target\n      where target.measure = &quot;Goal attainment scale&quot;\n    )\n    or exists goal.gasScores()</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"pcocommon-extensions\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\n@description: Returns any extensions defined on the given resource with the specified url.\n@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access\ncontent that is defined by extensions but not yet surfaced in the\nCQL model info.\n*/\ndefine fluent function extensions(domainResource DomainResource, url String):\n  domainResource.extension E\n\t  where E.url = url\n\t\treturn E</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"fhirhelpers-tostring\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToString(value uri): value.value</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-gasscores\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including only GAS scores\ndefine fluent function gasScores(goal Goal):\n  &quot;GAS Scores&quot; score\n    where score.focusGoals() contains goal</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-focusgoals\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Goal where focus includes the given Observation.\ndefine fluent function focusGoals(obs Observation):\n  obs.focus.resolveGoals()</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"pcocommon-resolvegoals\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define fluent function resolveGoals(references List&lt;Reference&gt;):\n  flatten( references ref\n    return [Goal] resource\n      where resource.id = ref.reference.getId()\n  )</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"pcocommon-getid\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define fluent function getId(uri String):\n  Last(Split(uri, '/'))</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-hasprom\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/// Returns true if this Goal has a PROM code in its target.measure\ndefine fluent function hasPROM(goal Goal):\n  exists (goal.target target\n    where target.measure in &quot;PROM Target Measures&quot;\n  )</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"pcocommon-careplans\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> PCOCommon</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of CarePlan that support this Goal.\ndefine fluent function carePlans(goal Goal):\n  [CarePlan] carePlan\n    where exists ( carePlan.goal goalRef\n        where goal.id = goalRef.reference.getId()\n    )</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-pcoscores\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including both GAS and PROM scores\ndefine fluent function pcoScores(goal Goal):\n  goal.gasScores()\n    union goal.promScores()</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-promscores\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">// Returns a list of Observation including only PROM scores\ndefine fluent function promScores(goal Goal):\n  &quot;PROM Scores&quot; score\n    where score.focusGoals() contains goal</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"fhirhelpers-todatetime\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> FHIRHelpers</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">define function ToDateTime(value dateTime): value.value</code></pre>\n  </td>\n\n</tr>\n        \n<tr>\n  <th scope=\"row\" rowspan=\"2\" class=\"row-header\">\n    \n      \n      <a name=\"goalattainmentlogic-follow-up-interval-for\"> </a>\n    \n    Logic Definition\n  </th>\n\n  <td class=\"content-container\"><em>Library Name:</em> GoalAttainmentLogic</td>\n\n</tr>\n<tr>\n\n  <td>\n    <pre style=\"border: none;\" class=\"content-container highlight language-cql\"><code class=\"language-cql\">/*\nComputes the follow-up interval for a Goal based on this measure's &quot;Follow-Up Interval&quot; parameter.\n@return Interval&lt;DateTime&gt;\n*/\ndefine function &quot;Follow-Up Interval For&quot; (goal Goal):\n  goal goal\n    let startDate: ToDateTime(goal.start as FHIR.date)\n      return Interval(startDate + start of &quot;Follow-Up Interval&quot;, startDate + end of &quot;Follow-Up Interval&quot;)</code></pre>\n  </td>\n\n</tr>\n\n  \n\n<tr>\n  <th colspan=\"2\" scope=\"row\" class=\"row-header\">Generated using version 0.4.6 of the sample-content-ig Liquid templates</th>\n</tr>\n    </tbody>\n  </table>\n</div>"
  },
  "contained" : [
    {
      "resourceType" : "Library",
      "id" : "effective-data-requirements",
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding" : {
            "system" : "http://loinc.org",
            "code" : "68489",
            "display" : "Goal attainment scale"
          }
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalFollowUpMeasure"
            },
            {
              "url" : "name",
              "valueString" : "Initial Population"
            },
            {
              "url" : "statement",
              "valueString" : "/*\n@description: Includes individuals 18 years of age and older.\n*/\ndefine \"Initial Population\": {\n  Patient person\n    where AgeInYearsAt(start of \"Measurement Period\") >= 18\n}"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 0
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalFollowUpMeasure"
            },
            {
              "url" : "name",
              "valueString" : "Denominator"
            },
            {
              "url" : "statement",
              "valueString" : "/*\n@description: Initial Population individuals with a complex care need and has a PCO Goal.\n@comment: TODO - How do we determine \"complex care need?\"\n*/\ndefine \"Denominator\":\n  \"Initial Population\""
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 1
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "PCO Goals"
            },
            {
              "url" : "statement",
              "valueString" : "/* \n  A \"PCO Goal\" is any FHIR Goal that has a category in \"PCO Categories\"\n  and has a start date.\n  TODO: or a Goal that addresses a What Matters observation.\n*/\ndefine \"PCO Goals\":\n  [Goal] goal\n    where goal.category in \"PCO Categories\"\n      and (goal.start as FHIR.date) is not null"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 2
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "GAS Scores"
            },
            {
              "url" : "statement",
              "valueString" : "// Observations containing a GAS score.\ndefine \"GAS Scores\":\n  [Observation: \"Goal Attainment Scaling (GAS) Score\"]"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 3
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "PCO Goals During Measurement Period"
            },
            {
              "url" : "statement",
              "valueString" : "// PCO Goals whose startDate falls within the Measurement Period\ndefine \"PCO Goals During Measurement Period\":\n  \"PCO Goals\" goal\n    where (ToDateTime(goal.start as FHIR.date) during \"Measurement Period\")\n      and (goal.hasGAS() or goal.hasPROM())\n      and exists goal.carePlans()"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 4
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
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              "valueString" : "PROM Scores"
            },
            {
              "url" : "statement",
              "valueString" : "// Observations containing a PROM score.\ndefine \"PROM Scores\":\n  [Observation: \"PROM Target Measures\"]"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 5
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
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              "valueString" : "Follow-Up Scores During Measurement Period"
            },
            {
              "url" : "statement",
              "valueString" : "/* \nFollow-Up Scares are PCO score observations taken during the Measurement Period,\nand during the follow-up period for its Goal. Default follow-up period is \n2 weeks to 6 months following the goal startDate.\n*/\ndefine \"Follow-Up Scores During Measurement Period\":\n  flatten( \"PCO Goals During Measurement Period\" goal\n    let pcoScores: goal.pcoScores()\n      return pcoScores score \n        let scoreDate: score.effective as FHIR.dateTime\n        where scoreDate during \"Measurement Period\"\n          and scoreDate during \"Follow-Up Interval For\"(goal)\n  )"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 6
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalFollowUpMeasure"
            },
            {
              "url" : "name",
              "valueString" : "Numerator"
            },
            {
              "url" : "statement",
              "valueString" : "/*\n@description: Indivuals who received follow-up on their PCO goal within two\nweeks to six months of when the PCO goal and GAS or PROM were identified.\n*/\ndefine \"Numerator\":\n  \"Denominator\" person\n    where exists PCOLogic.\"Follow-Up Scores During Measurement Period\""
            },
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              "url" : "displaySequence",
              "valueInteger" : 7
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
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            {
              "url" : "libraryName",
              "valueString" : "GoalFollowUpMeasure"
            },
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              "valueString" : "Denominator Exclusions"
            },
            {
              "url" : "statement",
              "valueString" : "define \"Denominator Exclusions\":\n  null"
            },
            {
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            },
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              "url" : "statement",
              "valueString" : "define \"Denominator Exceptions\":\n  null"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 9
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "FHIRHelpers"
            },
            {
              "url" : "name",
              "valueString" : "ToConcept"
            },
            {
              "url" : "statement",
              "valueString" : "/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n    if concept is null then\n        null\n    else\n        System.Concept {\n            codes: concept.coding C return ToCode(C),\n            display: concept.text.value\n        }"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 10
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "FHIRHelpers"
            },
            {
              "url" : "name",
              "valueString" : "ToDate"
            },
            {
              "url" : "statement",
              "valueString" : "define function ToDate(value date): value.value"
            },
            {
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          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "hasGAS"
            },
            {
              "url" : "statement",
              "valueString" : "// where exists obs.performer.resolveRelatedPersons()\n\ndefine fluent function hasGAS(goal Goal):\n  exists goal.extensions('http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-attainment-scaling')\n    or exists (goal.target target\n      where target.measure = \"Goal attainment scale\"\n    )\n    or exists goal.gasScores()"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 12
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "PCOCommon"
            },
            {
              "url" : "name",
              "valueString" : "extensions"
            },
            {
              "url" : "statement",
              "valueString" : "/*\n@description: Returns any extensions defined on the given resource with the specified url.\n@comment: NOTE: Extensions are not the preferred approach, but are used as a way to access\ncontent that is defined by extensions but not yet surfaced in the\nCQL model info.\n*/\ndefine fluent function extensions(domainResource DomainResource, url String):\n  domainResource.extension E\n\t  where E.url = url\n\t\treturn E"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 13
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "FHIRHelpers"
            },
            {
              "url" : "name",
              "valueString" : "ToString"
            },
            {
              "url" : "statement",
              "valueString" : "define function ToString(value uri): value.value"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 14
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "gasScores"
            },
            {
              "url" : "statement",
              "valueString" : "// Returns a list of Observation including only GAS scores\ndefine fluent function gasScores(goal Goal):\n  \"GAS Scores\" score\n    where score.focusGoals() contains goal"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 15
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "focusGoals"
            },
            {
              "url" : "statement",
              "valueString" : "// Returns a list of Goal where focus includes the given Observation.\ndefine fluent function focusGoals(obs Observation):\n  obs.focus.resolveGoals()"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 16
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "PCOCommon"
            },
            {
              "url" : "name",
              "valueString" : "resolveGoals"
            },
            {
              "url" : "statement",
              "valueString" : "define fluent function resolveGoals(references List<Reference>):\n  flatten( references ref\n    return [Goal] resource\n      where resource.id = ref.reference.getId()\n  )"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 17
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "PCOCommon"
            },
            {
              "url" : "name",
              "valueString" : "getId"
            },
            {
              "url" : "statement",
              "valueString" : "define fluent function getId(uri String):\n  Last(Split(uri, '/'))"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 18
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "hasPROM"
            },
            {
              "url" : "statement",
              "valueString" : "/// Returns true if this Goal has a PROM code in its target.measure\ndefine fluent function hasPROM(goal Goal):\n  exists (goal.target target\n    where target.measure in \"PROM Target Measures\"\n  )"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 19
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "PCOCommon"
            },
            {
              "url" : "name",
              "valueString" : "carePlans"
            },
            {
              "url" : "statement",
              "valueString" : "// Returns a list of CarePlan that support this Goal.\ndefine fluent function carePlans(goal Goal):\n  [CarePlan] carePlan\n    where exists ( carePlan.goal goalRef\n        where goal.id = goalRef.reference.getId()\n    )"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 20
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "pcoScores"
            },
            {
              "url" : "statement",
              "valueString" : "// Returns a list of Observation including both GAS and PROM scores\ndefine fluent function pcoScores(goal Goal):\n  goal.gasScores()\n    union goal.promScores()"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 21
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "promScores"
            },
            {
              "url" : "statement",
              "valueString" : "// Returns a list of Observation including only PROM scores\ndefine fluent function promScores(goal Goal):\n  \"PROM Scores\" score\n    where score.focusGoals() contains goal"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 22
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "FHIRHelpers"
            },
            {
              "url" : "name",
              "valueString" : "ToDateTime"
            },
            {
              "url" : "statement",
              "valueString" : "define function ToDateTime(value dateTime): value.value"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 23
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension" : [
            {
              "url" : "libraryName",
              "valueString" : "GoalAttainmentLogic"
            },
            {
              "url" : "name",
              "valueString" : "Follow-Up Interval For"
            },
            {
              "url" : "statement",
              "valueString" : "/*\nComputes the follow-up interval for a Goal based on this measure's \"Follow-Up Interval\" parameter.\n@return Interval<DateTime>\n*/\ndefine function \"Follow-Up Interval For\" (goal Goal):\n  goal goal\n    let startDate: ToDateTime(goal.start as FHIR.date)\n      return Interval(startDate + start of \"Follow-Up Interval\", startDate + end of \"Follow-Up Interval\")"
            },
            {
              "url" : "displaySequence",
              "valueInteger" : 24
            }
          ],
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        }
      ],
      "name" : "EffectiveDataRequirements",
      "status" : "active",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/library-type",
            "code" : "module-definition"
          }
        ]
      },
      "relatedArtifact" : [
        {
          "type" : "depends-on",
          "display" : "Library PCOLogic",
          "resource" : "http://hl7.org/fhir/us/pco/Library/GoalAttainmentLogic|0.1.0"
        },
        {
          "type" : "depends-on",
          "display" : "Library FHIRHelpers",
          "resource" : "http://hl7.org/fhir/us/pco/Library/FHIRHelpers|4.4.000"
        },
        {
          "type" : "depends-on",
          "display" : "Library PC",
          "resource" : "http://hl7.org/fhir/us/pco/Library/PCOCommon|0.1.0"
        },
        {
          "type" : "depends-on",
          "display" : "Code system LOINC",
          "resource" : "http://loinc.org"
        },
        {
          "type" : "depends-on",
          "display" : "Value set PCO Categories",
          "resource" : "http://hl7.org/fhir/us/pco/ValueSet/pco-category-valueset"
        },
        {
          "type" : "depends-on",
          "display" : "Value set Goal Attainment Scaling (GAS) Score",
          "resource" : "http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score"
        },
        {
          "type" : "depends-on",
          "display" : "Value set PROM Target Measures",
          "resource" : "http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures"
        }
      ],
      "parameter" : [
        {
          "name" : "Measurement Period",
          "use" : "in",
          "min" : 0,
          "max" : "1",
          "type" : "Period"
        },
        {
          "name" : "Follow-Up Interval",
          "use" : "in",
          "min" : 0,
          "max" : "1",
          "type" : "Range"
        },
        {
          "name" : "Numerator",
          "use" : "out",
          "min" : 0,
          "max" : "*",
          "type" : "Patient"
        },
        {
          "name" : "Denominator",
          "use" : "out",
          "min" : 0,
          "max" : "*",
          "type" : "Patient"
        },
        {
          "name" : "Initial Population",
          "use" : "out",
          "min" : 0,
          "max" : "*",
          "type" : "Patient"
        },
        {
          "name" : "Denominator Exclusions",
          "use" : "out",
          "min" : 0,
          "max" : "1",
          "type" : "Resource"
        },
        {
          "name" : "Denominator Exceptions",
          "use" : "out",
          "min" : 0,
          "max" : "1",
          "type" : "Resource"
        }
      ],
      "dataRequirement" : [
        {
          "type" : "Patient",
          "profile" : [
            "http://hl7.org/fhir/StructureDefinition/Patient"
          ]
        },
        {
          "type" : "Goal",
          "profile" : [
            "http://hl7.org/fhir/StructureDefinition/Goal"
          ],
          "mustSupport" : [
            "category",
            "start",
            "measure",
            "id"
          ]
        },
        {
          "type" : "Observation",
          "profile" : [
            "http://hl7.org/fhir/StructureDefinition/Observation"
          ],
          "mustSupport" : [
            "code"
          ],
          "codeFilter" : [
            {
              "path" : "code",
              "valueSet" : "http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score"
            }
          ]
        },
        {
          "type" : "Observation",
          "profile" : [
            "http://hl7.org/fhir/StructureDefinition/Observation"
          ],
          "mustSupport" : [
            "code"
          ],
          "codeFilter" : [
            {
              "path" : "code",
              "valueSet" : "http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures"
            }
          ]
        },
        {
          "type" : "CarePlan",
          "profile" : [
            "http://hl7.org/fhir/StructureDefinition/CarePlan"
          ],
          "mustSupport" : [
            "goal"
          ]
        }
      ]
    }
  ],
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem",
      "valueReference" : {
        "reference" : "Device/cqf-tooling"
      }
    },
    {
      "id" : "effective-data-requirements",
      "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements",
      "valueReference" : {
        "reference" : "#effective-data-requirements"
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/pco/Measure/GoalFollowUpMeasure",
  "identifier" : [
    {
      "use" : "usual",
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
            "code" : "short-name"
          }
        ]
      },
      "system" : "https://madie.cms.gov/measure/shortName",
      "value" : "PCOMeasure1"
    },
    {
      "use" : "official",
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
            "code" : "version-independent"
          }
        ]
      },
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:uuid:bc80e4cf-d267-47bf-ad0d-4d37f8ae2328"
    },
    {
      "use" : "official",
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
            "code" : "version-specific"
          }
        ]
      },
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:uuid:5c16a2fb-1882-49aa-802b-a0b73ed17c05"
    },
    {
      "use" : "official",
      "type" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
            "code" : "publisher"
          }
        ]
      },
      "system" : "https://madie.cms.gov/measure/cmsId",
      "value" : "NA",
      "assigner" : {
        "display" : "CMS"
      }
    }
  ],
  "version" : "0.2.0",
  "name" : "GoalFollowUpMeasure",
  "title" : "Person-Centered Goal Follow-Up",
  "status" : "active",
  "experimental" : false,
  "date" : "2024-12-11T00:23:37+00:00",
  "publisher" : "HL7 International / Patient Care",
  "contact" : [
    {
      "name" : "HL7 International / Patient Care",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/patientcare"
        },
        {
          "system" : "email",
          "value" : "patientcare@lists.HL7.org"
        }
      ]
    }
  ],
  "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.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US"
        }
      ]
    }
  ],
  "purpose" : "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.",
  "usage" : "Content TBD.",
  "copyright" : "Measure definition is copyright 2024 by NCQA.\n\nLOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.",
  "effectivePeriod" : {
    "start" : "2024-01-01",
    "end" : "2024-12-31"
  },
  "author" : [
    {
      "name" : "HL7 International / Patient Care",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/patientcare"
        }
      ]
    }
  ],
  "library" : [
    "http://hl7.org/fhir/us/pco/Library/GoalFollowUpMeasure"
  ],
  "disclaimer" : "These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty.",
  "scoring" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/measure-scoring",
        "code" : "proportion",
        "display" : "Proportion"
      }
    ]
  },
  "rationale" : "Goal-directed care in healthcare centers on setting and achieving specific, personalized goals that prioritize an individual's well-being and \"What Matters Most\" to each person. Rather than just treating symptoms, this approach involves close collaboration between patients, caregivers, and healthcare providers to identify individual goals related to health outcomes, functional improvement, or symptom management. Once goals are established, tailored care plans are developed, incorporating various treatments, therapies, and lifestyle adjustments to meet the individual's needs and preferences. Continual monitoring and adjustment ensure alignment with evolving priorities, fostering patient engagement and satisfaction while enhancing overall healthcare effectiveness.",
  "clinicalRecommendationStatement" : "None at this time.",
  "group" : [
    {
      "id" : "64f0d91d56d636294b157d97",
      "extension" : [
        {
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
          "valueCode" : "Patient"
        },
        {
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-type",
                "code" : "process",
                "display" : "Process"
              }
            ]
          }
        },
        {
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-rateAggregation",
          "valueString" : "None"
        },
        {
          "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-improvementNotation",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
                "code" : "increase",
                "display" : "Increased score indicates improvement"
              }
            ]
          }
        }
      ],
      "description" : "Content TBD",
      "population" : [
        {
          "id" : "692C6F6B-4153-496F-8582-0839A0816567",
          "code" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
                "code" : "initial-population",
                "display" : "Initial Population"
              }
            ]
          },
          "description" : "Individuals 18 years of age and older.",
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Initial Population"
          }
        },
        {
          "id" : "3116F1E4-8334-4CA0-9BEF-16CFEEDCB2A9",
          "code" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
                "code" : "denominator",
                "display" : "Denominator"
              }
            ]
          },
          "description" : "Individuals 18 years of age and older with a complex care need and has a PCO Goal.",
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Denominator"
          }
        },
        {
          "id" : "AA76FF0E-0EF9-40E6-9913-90FA63D50298",
          "code" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
                "code" : "denominator-exclusion",
                "display" : "Denominator Exclusion"
              }
            ]
          },
          "description" : "None",
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Denominator Exclusions"
          }
        },
        {
          "id" : "3D2BED97-5ADC-4210-8A3E-91B13652E7D0",
          "code" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
                "code" : "numerator",
                "display" : "Numerator"
              }
            ]
          },
          "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.",
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Numerator"
          }
        },
        {
          "id" : "4511743B-B054-4A08-800B-C4624450C38C",
          "code" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
                "code" : "denominator-exception",
                "display" : "Denominator Exception"
              }
            ]
          },
          "description" : "None",
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Denominator Exceptions"
          }
        }
      ]
    }
  ]
}

XIG built as of ??metadata-date??. Found ??metadata-resources?? resources in ??metadata-packages?? packages.