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When a patient visits Kevin Bozic, MD, MBA, to seek relief from longstanding knee pain, the surgeon looks at two key pieces of information: images of the knee and the patient’s self-reported pain, functional status, and quality of life.
Bozic, chair of the Department of Surgery and Perioperative Care at Dell Medical School, The University of Texas, and his colleagues are pioneers in the use of patient-reported outcome measures (PROMs) for shared decision-making, an important element of high-value healthcare services.
PROMs are validated instruments that use a patient’s response to questions to create a quantifiable measure of a health outcome or health status. PROMs allow a physician to understand a patient’s specific symptoms—for example, depression, anxiety, or
pain level—from the patient’s perspective.
“It’s giving the patient a voice in their health care,” says Judith Baumhauer, MD, MPH, associate chair of the Department of Orthopaedic Surgery at the University of Rochester Medical Center (URMC) in Rochester, N.Y. “We used to tell them how they’re doing. Now,
they’re telling us.”
When a patient’s baseline PROMs are compared with those of other patients with a similar condition, both patient and physician can
understand whether proceeding with surgery is worthwhile. Likewise, seeing the post-surgery PROMs for other patients helps the patient set realistic expectations for pain and functional ability in the weeks and months after surgery.
“We can tell from patients’ baseline pain, functional status, and mental health scores how likely they are to achieve a successful result from surgery,” Bozic says.
Shared decision-making, a major tenet of high-value health care, has been shown to reduce the nation’s healthcare tab. Up to 20 percent of patients who participate in a shared decision-making process
choose less-invasive surgical options. In a 2012
study published by Group Health, the use of decision aids to help patients who were considering hip and knee replacements resulted in 38 percent fewer surgeries over six months.
Shared decision-making empowers patients to choose treatments based on their values and preferences, but patients often have inadequate information to make fully informed decisions—for example, exactly how does my current pain level compare to the pain I will
likely experience during rehabilitation or after full recovery? PROMs allow a physician to show how a patient’s individual scores compare with those of similar patients to facilitate shared decision-making conversations.
Sample PROM Score Report
At URMC, PROMs have been collected for the past two years during every outpatient visit—about 17,000 a month—to the orthopedic surgery department. The medical center uses the
Patient-Reported Outcomes Measurement Information System (PROMIS), one of many measurement options.
Each patient’s appointment is linked to a QR-code reader that imports the appropriate PROMIS questions to a Wi-Fi-enabled computer tablet, which is given to the patient upon arrival at the clinic. Patients answer an average of four to seven questions. Physicians can immediately see the patient’s PROM scores in the
electronic health record (EHR) and compare them to scores from similar patients treated at URMC in the past two years.
That allows Baumhauer (pictured at right) and her colleagues to advise patients on how they can expect to fare after a given procedure.
“When a patient says, ‘Do you think I’m going to get better from having the surgery?’ I can look at their [PROM] scores and tell them with pretty good probability—94 percent probability in some cases—that they might not benefit from surgery and we ought to do something different,” she says. “That’s the
Holy Grail—having the vision to see the result ahead of time so the patient doesn’t have to try something that isn’t going to work.”
Traditionally gathered for research purposes, the idea of using PROMs for clinical decision-making has long held allure for physicians. But progress has been slow.
Dartmouth-Hitchcock Medical Center has been collecting PROMs for both clinical and research purposes for two decades. Today, those thousands of data points feed a calculator that lets patients see the outcomes of surgical versus nonsurgical interventions for
patients similar to them, as
reported recently in the New England Journal of Medicine. Partners HealthCare in Boston introduced PROMs in 2012 and has collected 1.2 million scores in 21 specialties, including urology, orthopedics, psychiatry, and primary care. After starting with orthopedic surgery PROMs in 2015, URMC has expanded collection
to 30 departments and divisions.
PROMs are at the center of a shared-decision making process that has been implemented in the Musculoskeletal Institute at UT Health Austin, where Bozic and his colleagues are working on ways to improve the value of care delivered to patients with arthritis.
Although PROMs are collected more widely for orthopedic surgery patients than for any other service line industry-wide, Bozic (pictured at right) says PROMs are rarely used in clinical decision-making even in that specialty. He estimates that perhaps 5 percent of orthopedic
specialists are collecting PROMs for the majority of their patients, mostly for research purposes.
“What percentage are collecting PROMs for every patient at every encounter and using them in clinical decision-making? I would say it’s far less than 1 percent,” he says.
He expects growth in the use of PROMs for shared decision-making to remain slow until value-based health care becomes more widespread. Although value-based payments are beginning to catch on for joint replacement surgeries, most new payment methodologies incentivize improvements
in the quality and efficiency of surgery—and do nothing to help patients decide whether surgery is their best course of action. Currently, most health plans and patients are not yet demanding the use of PROMs as an indicator of high-value medical practice. “Adoption is going to depend on how much the payer
community is willing to say, ‘This is important and we are going to start incentivizing this,’ and on patients being informed that this is important information that influences their treatment decisions,” Bozic says.
Medicare provides a quality incentive for hospitals in the Comprehensive Care for Joint Replacement program to report pre- and postoperative patient-reported functional outcomes, although the hospitals are not required to use those scores in any way.
As patients come to understand how PROMs can inform their decisions about major surgery, they are likely to gravitate to institutions that use such measures. Thus, value-oriented health systems should start preparing for the day when using PROMs for shared
decision-making becomes a competitive advantage. Pioneers such as Partners have found that gearing up for PROMs to become a seamless part of decision-making takes years.
“We certainly have the battle scars you’d expect from such a complex endeavor—asking people to do yet one more thing, to incorporate yet one more piece of technology,” Neil Wagle, MD, MBA, Partners’ associate quality officer, said in an
NEJM Catalyst article.
Like most important initiatives, the collection and use of PROMs requires a wide range of resources and, thus, support from top leaders. At URMC, implementing PROMs is an element of the institution’s strategic plan, Baumhauer says. “That’s how important our leaders think this
is, which is fantastic,” Baumhauer says. “It’s hard to get that level of institutional support, and we do have it.”
Those at the forefront identified issues that need early consideration:
Technology. Ensuring a 100 percent reliable wireless network in every location where PROMs will be collected is an important first step. PROMs are generally collected using computer tablets when patients first arrive at an outpatient clinic (unless patients
have used an online portal to answer questions in advance of their visit). Unreliable wireless connections wreak havoc: Patients get frustrated with the devices, PROM data does not get relayed to the patient’s EHR in time for the appointment, and the technology problem becomes a new source of physician stress
and, potentially, burnout.
Choosing the right technology platform is also an important early step. At Partners, PROMs are integrated into the EHR. Patients can answer their PROM questions at home using the patient portal or in the clinic. URMC, in contrast, uses a third-party platform
that sits outside the EHR, although PROM data flows into patients’ electronic records for physicians to view. Each system has advantages and disadvantages that should be carefully weighed.
Physician support. The physicians in Bozic’s department at Dell Medical School have chosen to use PROMs for shared decision-making, but that perspective is not necessarily universal. At first, the use of PROM data seems like another task placed
on an already overburdened clinician. It takes a while for physicians to learn how to read the data quickly and incorporate it into a shared decision-making conversation.
That’s why the PROM journey should start with a physician champion in a specialty where PROMs are validated and understood to be of value in clinical decision-making. The champion should be able to convince his or her peers that using PROMs is good for their patients—the
only message that is likely to get them on board.
Patient buy-in. Patients are already burdened with tasks—providing insurance information, signing HIPAA forms, filling out health histories—before their physician appointment, and they are not eager to take on more. At URMC, every department asks patients to report on three things—physical
function, pain interference, and depression—in a questionnaire that takes an average of 2.4 minutes to complete. Some departments add extra domains such as anxiety, fatigue, or social isolation when those are relevant to the patients they treat.
“Every time you add in an additional domain, it takes about a minute,” Baumhauer says. “We have a philosophy of trying to decrease patient burden, so we want to keep it under five minutes.”
Unless patients see exactly how the physician is using PROM data, the response rate on the questionnaires will be low, Bozic says. However, patients expect to put in considerable effort to get an X-ray—arriving early, waiting, exposing themselves to radiation, even hand-carrying a CD—because they
understand its relevance to the physician’s understanding of their condition. That’s why Bozic’s protocol is to use a patient’s PROM data just as he uses an X-ray image, showing it to the patient and explaining how it informs treatment decisions.
Despite the challenges associated with collecting and using PROMs for clinical decision-making, pioneers believe these measures will become the standard of care in the foreseeable future.
Researchers at Partners recently conducted
qualitative interviews with 25 physicians and non-physician providers to learn how PROMs affect providers and patients. Less than five years after a robust PROM program was initiated at that health system, some providers have evolved from skeptics to cheerleaders.
“Our interviews suggested that use of PROs can improve physician satisfaction, enhance physician-patient relationships, increase workflow efficiency and enable crucial conversations,” the authors wrote. “Despite [the] challenges, we believe PROs have the
potential to reengage patients and physicians in the care delivery process.”
Lola Butcher writes about healthcare business and policy topics for several HFMA publications.
Interviewed for this article:
Judith Baumhauer, MD, MPH, is professor and associate chair of the Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, N.Y.;
Kevin Bozic, MD, MBA, is professor and chair of the Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas, Austin.
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