Desired state to be achieved by a person or a person’s elections to guide care.

Data Element
Patient Goal Category
Submitted By: Grace Glennon, on behalf of NCQA / NCQA
Data Element Information
Data Element Description Domain of the stated patient goal.
Examples of goal categories include housing, physical function, behavioral, and social & role functioning.
Rationale for Separate Consideration While Patient goals is an element included in USCDI, this element is intended to describe the higher-level domain of patient goals. Sharing of goal categories (or goal domains) allows for a high level understanding of the goal focus and supports population health-level decision making as organizations can better understand what matters most to their clients/consumers and can tailor their funding, focus and services based on these goal domains.
Use Case Description(s)
Use Case Description Over the past 10 years, NCQA has worked on person-centered outcome measures and demonstrated exchange of patient goal data. Inclusion of person-centered information in care continues to be a priority across the ecosystem. Sharing of critical patient-centered data across care settings supports prioritization of a person’s well-being rather than just treating symptoms.
NCQA has identified and standardized 12 high-level goal domains that individuals identify as what matters most to them. For the PCO measures, we require collection of a goal domain for two reasons. First, it allows us to understand that a goal conversation occurred as well as the focus of the individuals goals. Second, goal categories or domains support population health. As goal domains are identified, organizations and health plans gain a better understanding of what matters most to their clients/consumers and can tailor their funding, focus and services based on these goal domains.

NCQA identified Goal Domains:
• Access to Services & Supports
• Caregiver Needs & Concerns
• Emotional & Mental Health
• End of Life
• Housing
• Improving Health & Wellness
• Independence
• Legal
• Managing Conditions & Symptoms
• Medication Management
• Physical Function
• Social & Role Functioning
Estimate the breadth of applicability of the use case(s) for this data element (Level 2) – Use cases apply to most care settings or specialties.
Person-centered care is important across all care settings, particularly when supporting persons with multiple chronic conditions.
Link to use case project page https://www.ncqa.org/hedis/reports-and-research/pco-measures/
Use Case Description Many other person-centered outcomes research, such as the MCC eCare Plan project are also working towards similar goals.
Estimate the breadth of applicability of the use case(s) for this data element Person-centered care and patient goals are critical to include in all aspects of care, particularly when supporting persons with multiple chronic conditions.
Link to use case project page https://hl7.org/fhir/us/mcc/2023Sep/
ONC Priority
  • Address behavioral health integration with primary care and other physical care
  • Mitigate health and health care inequities and disparities
  • Address the needs of underserved communities
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) HL7 Terminology: Goal Category.

NCQA is also actively working with the HL7 Patient Goals work group to update the HL7 terminology for “goal category” to include additional patient goal categories aligned to our work.

https://hl7.org/fhir/R4/valueset-goal-category.html
Additional Specifications US Core Goal profile – (.category)
Current Use (Level 1) Captured, stored, or accessed in at least one production EHR or HIT module
Extent of exchange (Level 1) Between two production EHRs or other HIT modules using available interoperability standards
Supporting Artifacts Patient-centered data collection, including patient goal information, is continuing to be more widely practiced. NCQA is currently working with testing partners to digitally collect and exchange this information.

In addition, Patient Goals is an included USCDI element. Because Goal Category or Domain is associated with patient goals, we expect that this element is being used and exchanged by at least some systems.

Testing also continues at HL7 Connectathons.
https://confluence.hl7.org/display/FHIR/2024+-+05+Goal-Directed+Care+Planning
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No restrictions.
Restrictions on Use (e.g. licensing, user fees) No restrictions.
Privacy and Security Concerns Exchange of patient health information should follow HIPPA Privacy Rules.
Estimate of Overall Burden Patient goals, and person centered care is increasingly of priority to health care providers. Capture of goal categories does require an additional documentation step after individual patient goals are identified and documented.
ASTP Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 1 - Data element is captured, stored, or accessed in at least one production EHR or HIT module.
Criterion #3
Maturity - Current Exchange		 Level 0 - Data element is electronically exchanged in limited environments, such as connectathons or pilots.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 1 - Use cases apply to several care settings or specialties.

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