Updates to improve What Matters observations and support Patient Prio…

…rities Care

FHIR-us-pco.xml

@@ -4,7 +4,6 @@
 <artifactPageExtension value="-definitions"/>
 <artifactPageExtension value="-examples"/>
 <artifactPageExtension value="-mappings"/>
-<artifact id="StructureDefinition/pco-bothersome-health-concern" key="StructureDefinition-pco-bothersome-health-concern" name="Bothersome Health Concern"/>
 <artifact id="CodeSystem/pco-bothersome-health-concern-concepts" key="CodeSystem-pco-bothersome-health-concern-concepts" name="Bothersome Health Concern Concepts"/>
 <artifact id="ValueSet/pco-bothersome-health-concern-valueset" key="ValueSet-pco-bothersome-health-concern-valueset" name="Bothersome Health Concern Example ValueSet"/>
 <artifact id="CarePlan/pcoAnxietyCarePlanExample" key="CarePlan-pcoAnxietyCarePlanExample" name="Care Plan for PCO Anxiety Goal"/>
@@ -17,10 +16,8 @@
 <artifact id="CodeSystem/pco-care-tradeoff-choices" key="CodeSystem-pco-care-tradeoff-choices" name="Care Trade-off Choices"/>
 <artifact id="ValueSet/pco-care-tradeoff-choices-valueset" key="ValueSet-pco-care-tradeoff-choices-valueset" name="Care Trade-off Choices ValueSet"/>
 <artifact id="CodeSystem/pco-care-tradeoff-concepts" key="CodeSystem-pco-care-tradeoff-concepts" name="Care Trade-off Concepts"/>
-<artifact id="ValueSet/pco-care-tradeoff-valueset" key="ValueSet-pco-care-tradeoff-valueset" name="Care Trade-off Example ValueSet"/>
+<artifact id="ValueSet/pco-care-tradeoff-valueset" key="ValueSet-pco-care-tradeoff-valueset" name="Care Trade-off ValueSet"/>
 <artifact id="CodeSystem/pco-codes" key="CodeSystem-pco-codes" name="Codes for PCO"/>
-<artifact id="Patient/pcoPatientLopez" key="Patient-pcoPatientLopez" name="Example Patient Camila"/>
-<artifact id="Patient/pcoPatientJones" key="Patient-pcoPatientJones" name="Example Patient Dorothy"/>
 <artifact id="Library/FHIRHelpers" key="Library-FHIRHelpers" name="FHIRHelpers"/>
 <artifact id="ValueSet/gas-score-answers" key="ValueSet-gas-score-answers" name="Follow-Up GAS Score Answers"/>
 <artifact id="Observation/pcoPROMScoreAnxietyExample" key="Observation-pcoPROMScoreAnxietyExample" name="GAD-7 PROM Follow-up Score"/>
@@ -29,6 +26,7 @@
 <artifact id="StructureDefinition/pco-goal-attainment-scaling" key="StructureDefinition-pco-goal-attainment-scaling" name="Goal Attainment Scaling"/>
 <artifact id="ValueSet/goal-attainment-scaling-score" key="ValueSet-goal-attainment-scaling-score" name="Goal Attainment Scaling (GAS) Score"/>
 <artifact id="StructureDefinition/pco-gas-score-observation" key="StructureDefinition-pco-gas-score-observation" name="Goal Attainment Scaling (GAS) score"/>
+<artifact id="ValueSet/goal-barrier-codes" key="ValueSet-goal-barrier-codes" name="Goal Barrier Assessment Codes"/>
 <artifact id="Goal/pcoGoalAnxietyExample" key="Goal-pcoGoalAnxietyExample" name="Goal for GAD-7 PROM Outcome"/>
 <artifact id="Goal/pcoGoalWalkDogExample" key="Goal-pcoGoalWalkDogExample" name="Goal with GAS"/>
 <artifact id="Goal/pcoGoalWalkDogExampleWithoutExtensions" key="Goal-pcoGoalWalkDogExampleWithoutExtensions" name="Goal without GAS Extensions"/>
@@ -37,32 +35,48 @@
 <artifact id="Library/GoalFollowUpMeasure" key="Library-GoalFollowUpMeasure" name="GoalFollowUpMeasure"/>
 <artifact id="Library/GoalIdentificationMeasure" key="Library-GoalIdentificationMeasure" name="GoalIdentificationMeasure"/>
 <artifact id="Practitioner/pcoPractitionerGonzalez" key="Practitioner-pcoPractitionerGonzalez" name="Health &amp; Wellness Coach"/>
-<artifact id="ValueSet/pco-domain-category-valueset" key="ValueSet-pco-domain-category-valueset" name="PCO Domain Categories"/>
+<artifact id="ValueSet/pco-goal-domains-example-vs" key="ValueSet-pco-goal-domains-example-vs" name="PCO Goal Domain Categories Example"/>
 <artifact id="CodeSystem/pco-goal-domains" key="CodeSystem-pco-goal-domains" name="PCO Goal Domains"/>
 <artifact id="Library/PCOCommon" key="Library-PCOCommon" name="PCOCommon"/>
 <artifact id="Questionnaire/44249-1" key="Questionnaire-44249-1" name="PHQ-9 quick depression assessment panel"/>
+<artifact id="Observation/ppcBarrierDiabetes" key="Observation-ppcBarrierDiabetes" name="PPC Bothersome Health Concern: Diabeted diet (other)"/>
+<artifact id="Observation/ppcBarrierUnsteady" key="Observation-ppcBarrierUnsteady" name="PPC Bothersome Symptom: Feeling Unsteady"/>
+<artifact id="CarePlan/ppcCookingDinnerCarePlanExample" key="CarePlan-ppcCookingDinnerCarePlanExample" name="PPC Care Plan for person-centered goal"/>
+<artifact id="ServiceRequest/ppcPhysicalTherapyReferral" key="ServiceRequest-ppcPhysicalTherapyReferral" name="PPC Care Plan: Clinical action step for PT"/>
+<artifact id="Observation/ppcCareTradeOffBothersome" key="Observation-ppcCareTradeOffBothersome" name="PPC Care Trade-Off: Following a special diet"/>
+<artifact id="Observation/ppcCareTradeOffHelpful" key="Observation-ppcCareTradeOffHelpful" name="PPC Care Trade-Off: Health care visits"/>
+<artifact id="Observation/ppcGASScoreBaselineExample" key="Observation-ppcGASScoreBaselineExample" name="PPC GAS Baseline Score"/>
+<artifact id="Goal/ppcGoalCookingDinner" key="Goal-ppcGoalCookingDinner" name="PPC Goal: Cooking Dinner"/>
+<artifact id="List/ppcPrioritiesList" key="List-ppcPrioritiesList" name="PPC Priorities List"/>
+<artifact id="CodeSystem/ppc-what-matters-concepts" key="CodeSystem-ppc-what-matters-concepts" name="PPC What Matters Concepts"/>
+<artifact id="ValueSet/ppc-what-matters-example-vs" key="ValueSet-ppc-what-matters-example-vs" name="PPC What Matters Example ValueSet"/>
+<artifact id="Observation/ppcWhatMattersActivitiesWithFamily" key="Observation-ppcWhatMattersActivitiesWithFamily" name="PPC What Matters: Activities with Family"/>
+<artifact id="Observation/ppcWhatMattersMovingTheBody" key="Observation-ppcWhatMattersMovingTheBody" name="PPC What Matters: Walking or moving"/>
 <artifact id="ValueSet/prom-target-measures" key="ValueSet-prom-target-measures" name="PROM Target Measures"/>
+<artifact id="Patient/pcoPatientLopez" key="Patient-pcoPatientLopez" name="Patient Camila Lopez"/>
+<artifact id="Patient/pcoPatientJones" key="Patient-pcoPatientJones" name="Patient Dorothy Jones"/>
 <artifact id="Observation/pcoGASScorePatientFollowupExample" key="Observation-pcoGASScorePatientFollowupExample" name="Patient GAS Follow-up Score"/>
+<artifact id="Patient/ppcPatientKay" key="Patient-ppcPatientKay" name="Patient John Kay"/>
 <artifact id="StructureDefinition/pco-prom-score-observation" key="StructureDefinition-pco-prom-score-observation" name="Patient-Reported Outcome Measure (PROM) score"/>
 <artifact id="StructureDefinition/pco-care-plan" key="StructureDefinition-pco-care-plan" name="Person-Centered Care Plan"/>
-<artifact id="ValueSet/pco-category-vs" key="ValueSet-pco-category-vs" name="Person-Centered Category Value Set"/>
 <artifact id="StructureDefinition/pco-gas-goal-profile" key="StructureDefinition-pco-gas-goal-profile" name="Person-Centered GAS Goal"/>
 <artifact id="StructureDefinition/pco-goal-profile" key="StructureDefinition-pco-goal-profile" name="Person-Centered Goal"/>
+<artifact id="StructureDefinition/pco-goal-barrier" key="StructureDefinition-pco-goal-barrier" name="Person-Centered Goal Barrier"/>
 <artifact id="Measure/GoalFollowUpMeasure" key="Measure-GoalFollowUpMeasure" name="Person-Centered Goal Follow-Up"/>
 <artifact id="Measure/GoalIdentificationMeasure" key="Measure-GoalIdentificationMeasure" name="Person-Centered Goal Identification"/>
 <artifact id="ValueSet/pco-survey-category-vs" key="ValueSet-pco-survey-category-vs" name="Person-Centered Outcomes Survey Value Set"/>
 <artifact id="StructureDefinition/pco-prom-goal-profile" key="StructureDefinition-pco-prom-goal-profile" name="Person-Centered PROM Goal"/>
+<artifact id="StructureDefinition/pco-personal-priorities-organizer" key="StructureDefinition-pco-personal-priorities-organizer" name="Personal Priorities Organizer"/>
 <artifact id="Observation/pcoGASScorePractitionerFollowupExample" key="Observation-pcoGASScorePractitionerFollowupExample" name="Practitioner GAS Follow-up Score"/>
 <artifact id="Practitioner/pcoPractitionerAnderson" key="Practitioner-pcoPractitionerAnderson" name="Primary Care Physician"/>
 <artifact id="CodeSystem/va-whole-health-example" key="CodeSystem-va-whole-health-example" name="VA Whole Health Concepts"/>
 <artifact id="ValueSet/wellbeing-category-vs" key="ValueSet-wellbeing-category-vs" name="Well-Being Categories"/>
 <artifact id="CodeSystem/wellbeing-concepts" key="CodeSystem-wellbeing-concepts" name="Well-Being Concepts"/>
 <artifact id="ValueSet/wellbeing-domains-example-vs" key="ValueSet-wellbeing-domains-example-vs" name="Well-Being Domains Example"/>
-<artifact id="ValueSet/wellbeing-priority-focus-vs" key="ValueSet-wellbeing-priority-focus-vs" name="Well-Being Priority Or Focus"/>
 <artifact id="StructureDefinition/pco-what-matters-assessment" key="StructureDefinition-pco-what-matters-assessment" name="What Matters Assessment"/>
-<artifact id="StructureDefinition/pco-what-matters-priority-focus" key="StructureDefinition-pco-what-matters-priority-focus" name="What Matters Priority or Focus Area"/>
+<artifact id="ValueSet/what-matters-vs" key="ValueSet-what-matters-vs" name="What Matters Categories"/>
+<artifact id="StructureDefinition/pco-what-matters-priority" key="StructureDefinition-pco-what-matters-priority" name="What Matters Priority"/>
 <artifact id="Observation/pcoWhatMattersPriorityExample" key="Observation-pcoWhatMattersPriorityExample" name="What Matters Priority: Moving the Body"/>
-<artifact id="StructureDefinition/pco-what-matters-statement" key="StructureDefinition-pco-what-matters-statement" name="What Matters Statement"/>
 <artifact id="Observation/pcoWhatMattersStatementExample" key="Observation-pcoWhatMattersStatementExample" name="What Matters Statement: Family &amp; Friends"/>
 <artifact id="Observation/pcoWhatMattersRelationshipsExample" key="Observation-pcoWhatMattersRelationshipsExample" name="What Matters: Family &amp; Friends"/>
 <artifact id="Observation/pcoWhatMattersBodyExample" key="Observation-pcoWhatMattersBodyExample" name="What Matters: Moving the Body"/>

input/cql/GoalAttainmentLogic.cql

@@ -4,12 +4,10 @@ using FHIR version '4.0.1'
 
 include FHIRHelpers version '4.4.000' called FHIRHelpers
 include PCOCommon version '0.1.0' called PC
+include WhatMattersLogic version '0.1.0' called WM
 
 codesystem "LOINC": 'http://loinc.org'
-// codesystem "PCO GAS Codes": 'http://hl7.org/fhir/us/pco/CodeSystem/pco-gas-codes-temporary'
-
-valueset "Person-Centered Category": 'http://hl7.org/fhir/us/pco/ValueSet/pco-category-vs'
-valueset "PCO Domain Categories": 'http://hl7.org/fhir/us/pco/ValueSet/pco-domain-category-valueset'
+valueset "PCO Goal Domain Categories": 'http://hl7.org/fhir/us/pco/ValueSet/pco-goal-domains-example-vs'
 valueset "Goal Attainment Scaling (GAS) Score": 'http://hl7.org/fhir/us/pco/ValueSet/goal-attainment-scaling-score'
 valueset "Follow-Up GAS Score Answers": 'http://hl7.org/fhir/us/pco/ValueSet/gas-score-answers'
 valueset "PROM Target Measures": 'http://hl7.org/fhir/us/pco/ValueSet/prom-target-measures'
@@ -33,7 +31,9 @@ define GoalSummary:
     return {
       id: goal.id.value,
       dueDate: goal.dueDate(),
-      pcoCategories: goal.category in "Person-Centered Category",
+      whatMattersCategory: goal.category in WM."What Matters Categories",
+      goalDomainCategory: goal.category in "PCO Goal Domain Categories",
+      addressesWhatMatters: exists goal.whatMattersObservations(),
       hasGAS: goal.hasGAS(),
       hasPROM: goal.hasPROM(),
       carePlans: goal.carePlans()
@@ -52,14 +52,15 @@ define "All Goals":
   [Goal] goal
 
 /* 
-  A "PCO Goal" is any FHIR Goal that has a category in "Person-Centered Category" or "PCO Domain Categories"
+  A "PCO Goal" is any FHIR Goal that has a category in "What Matters Category" or "PCO Domain Categories"
+      or that addresses a What Matters observation
   and has a start date.
-  TODO: or a Goal that addresses a What Matters observation.
 */
 define "PCO Goals":
   [Goal] goal
-    where (goal.category in "Person-Centered Category"
-        or goal.category in "PCO Domain Categories")
+    where (goal.category in WM."What Matters Categories"
+        or goal.category in "PCO Goal Domain Categories"
+        or exists goal.whatMattersObservations())
       and (goal.start as FHIR.date) is not null
 
 // A "GAS Goal" is any PCO Goal that includes GAS extensions

input/cql/PCOCommon.cql

@@ -32,6 +32,13 @@ define fluent function addressesConditions(goal Goal):
         where obs.id = GA.reference.getId()
   )
 
+// Returns a list of Observations that this Goal addresses.
+define fluent function addressesObservations(goal Goal):
+  flatten( goal.addresses GA
+      return [Observation] obs
+        where obs.id = GA.reference.getId()
+  )
+
 // Returns a list of Goals that address this Observation
 define fluent function addressedByGoals(obs Observation):
   [Goal] goal

input/cql/WhatMattersLogic.cql

@@ -5,7 +5,7 @@ using FHIR version '4.0.1'
 include FHIRHelpers version '4.4.000' called FHIRHelpers
 include PCOCommon version '0.1.0' called PC
 
-valueset "Well-Being Categories": 'http://hl7.org/fhir/us/pco/ValueSet/wellbeing-category-vs'
+valueset "What Matters Categories": 'http://hl7.org/fhir/us/pco/ValueSet/what-matters-vs'
 valueset "Well-Being Domains": 'http://hl7.org/fhir/us/pco/ValueSet/wellbeing-domains-example-vs'
 
 parameter "Measurement Period" Interval<DateTime>
@@ -18,7 +18,7 @@ context Patient
 
 define "What Matters Observations":
   [Observation] obs
-    where obs.category in "Well-Being Categories"
+    where obs.category in "What Matters Categories"
       or obs.code in "Well-Being Domains"
 
 // Returns a list of what matters Observations this Goal addresses.
@@ -31,17 +31,3 @@ define fluent function whatMattersObservations(goal Goal):
 
 define fluent function isWhatMatters(obs Observation):
   "What Matters Observations" contains obs
-
-// Returns a list of Goals that address this Observation
-define fluent function addressedByGoals(obs Observation):
-  [Goal] goal
-    where exists ( goal.addresses GA
-        where obs.id = GA.reference.getId()
-    )
-
-// Returns a list of Conditions that this Goal addresses.
-define fluent function addressesConditions(goal Goal):
-  flatten( goal.addresses GA
-      return [Condition] obs
-        where obs.id = GA.reference.getId()
-  )

input/fsh/GASExamples.fsh

@@ -6,6 +6,7 @@ Description: "Person-centered goal with attainment scaling extensions"
 Usage: #example
 * lifecycleStatus = #active
 * achievementStatus = $GoalAchievement#in-progress
+* category[what-matters] = WellBeingConcepts#what-matters "What Matters Most"
 * category[goal-domain] = PCOGoalDomains#physical-function "Physical Function"
 * subject = Reference(pcoPatientJones)
 * expressedBy = Reference(pcoPatientJones)
@@ -32,6 +33,7 @@ Description: "Person-centered goal with GAS target measure and without GAS exten
 Usage: #example
 * lifecycleStatus = #active
 * achievementStatus = $GoalAchievement#in-progress
+* category[what-matters] = WellBeingConcepts#what-matters "What Matters Most"
 * category[goal-domain] = PCOGoalDomains#physical-function "Physical Function"
 * subject = Reference(pcoPatientJones)
 * expressedBy = Reference(pcoPatientJones)