Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Data Element
Goal Assessment
Description

The assessment and monitoring of goals and goal progress.

Examples for goal assessments include Goal Attainment Scaling (GAS) and patient-reported outcome measures (PROMs) such as PHQ-9, GAD-7 or PROMIS.
Submitted By: Grace Glennon-Jubrey (NCQA) / NCQA
Data Element Information
Data Element Description The assessment and monitoring of goals and goal progress.

Examples for goal assessments include Goal Attainment Scaling (GAS) and patient-reported outcome measures (PROMs) such as PHQ-9, GAD-7 or PROMIS.
Rationale for Separate Consideration While there are some health status assessment elements that may include tools that could be used for goal tracking (and other purposes), such as mental/cognitive status, this element distinctly defines requirements for assessing and monitoring goals, regardless of the assessment tool used to do so.
Use Case Description(s)
Use Case Description Over the past 10 years, NCQA has worked on the person-centered outcome (PCO) 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. While patient goals are included in USCDI, standardized assessment tools to monitor and track goal progress are a critical missing component to USCDI.

NCQA has identified and uses standardized tools to track and monitor progress on individualized goals of care. For the PCO measures, we require the use of a standardized tool, such as goal attainment scaling or PROMIS tools, to track and assess goals overtime. This allows patients, caregivers and clinicians to meaningfully and standardly track progress on goals and have meaningful conversations related to individual goals.
Estimate the breadth of applicability of the use case(s) for this data element (Level 1) – Use cases apply to several care settings or specialties.
Link to use case project page https://www.ncqa.org/hedis/reports-and-research/pco-measures/
Use Case Description The Person-Centered Outcomes (PCO) HL7® FHIR® Implementation Guide (IG) supports the exchange of information related to person-centered care guided by a person-centered outcomes approach, which includes the identification and tracking of personal outcome goals that matter most to patients using either Goal Attainment Scaling (GAS) or patient-reported outcome measures (PROM).

The PCO IG includes profiles for interoperable GAS Goals, support for goal editing tools, and PCO measures. 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. GAS involves collaboratively setting goals with the individual and assigning numerical scales to each goal to represent different levels of achievement. This approach provides a more nuanced and tailored way to assess progress and outcomes, taking into account the unique circumstances and aspirations of the individual.
Estimate the breadth of applicability of the use case(s) for this data element (Level 1) – Use cases apply to several care settings or specialties.
Link to use case project page https://build.fhir.org/ig/HL7/pco-ig/index.html
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) Standardized goal assessment tools exist and have associated LOINC terminology codes.

Examples:
• 107332-9-- Goal attainment scale – Reported
• 107334-5 -- Patient follow-up goal attainment scaling score
• 107333-7-- Practitioner follow-up goal attainment scaling score
• 77854-8 -- PROMIS© Ability to Participate in Social Roles and Activities - Short Form v2.0 - 8a
• 92418-3 -- PROMIS© Self-Efficacy for Managing Medications and Treatments - Short Form v1.0 - 8a
• 70274-6-- General Anxiety Disorder (GAD) - 7
• 44261-6 -- PHQ-9
https://loinc.org/
Additional Specifications Person-Centered Outcomes (PCO) Implementation Guide, being balloted in Fall 2025: https://build.fhir.org/ig/HL7/pco-ig/index.html
• This IG includes guidance on tracking goal progress and use of GAS and PROMs via Observation FHIR resource.

The PCO IG reference US Core Observation Screening Assessment profile (https://hl7.org/fhir/us/core/STU6.1/StructureDefinition-us-core-observation-screening-assessment.html), which can be used to exchange goal assessment data. In US Core, the element necessary to capture the goal assessment are must have and must support elements.
• Status (must have)
• Code (must have)
• Value (must support)
• Effective time (must support)
Current Use (Level 2) Captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer
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. The use of standardized assessment tools for goal tracking (GAS, PROMs) has been successfully tested via the PCO in multiple care delivery settings in over 40 practices, across 17 states, with more than 750 clinicians (e.g., physicians, nurses, social workers, peer navigators and care managers) and over 30,000 individuals.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) No restrictions; No proprietary codes.
Restrictions on Use (e.g. licensing, user fees) No restrictions.
Privacy and Security Concerns No unique 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 progress via standardized assessment tools should be a routine step once person-centered goals are identified. Goals and Care Plan, two important steps in the goal conversation, are already included in USCDI. Standardized tools with associated codes already exist and are in use today.
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 0 - Data element is not 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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