For anyone who has travelled on the London Metro, “mind the gap” means watching your step between the subway car and the platform when you enter and exit. In healthcare, we are constantly mindful of the gaps we are aware of, but some are more difficult to see. One example is in the way we measure the value of care delivery. Current measurements often focus on observation from professionals and objective clinical data like range of motion, blood pressure readings, and laboratory data. However, we can now incorporate another critically important metric: Patient Reported Outcome Measures (PROMs).
What exactly are PROMs? They are data that a patient provides us about their condition, diagnosis, and/or treatment. Patient reported outcomes are commonly obtained using validated patient surveys that include functional and quality of life measures. Why are patient reported outcome measures important? Because they provide us with the most meaningful data that will help us improve health and well-being.
"By using PROMs data, patients can understand their progress and how it compares to the broader population’s outcomes for the same procedure"
There is no standard playbook for collecting PROMs. Some organizations will gather data with a traditional hardcopy survey while other providers will use sophisticated information systems. There are many free validated options available and the National Institutes of Health has options available through their Patient Reported Outcomes Measurement Information System (PROMIS). But regardless of the tool, the most important success factors to gathering information are engaged patients and physicians.
Our patients have been intimately involved with the design of our processes. At the physician’s office, our patients can use a tablet, such as an iPad, to enter their PROMs data. Or, the data can be collected via an emailed survey. Paper surveys are also available but most patients prefer a more modern method of collection.
Physician buy-in is also necessary for adoption. Clinicians should be involved in selecting the survey instrument. When it comes to specific survey questions, it’s best to reach a consensus among the physician group. Fortunately, there are many patient reported questionnaire templates available. Specialty societies also have recommendations and specific tools that should be implemented. However, err on the side of simplicity whenever possible. Asking too much can reduce patients’ completion rates. Likewise, physicians should plan to use the information during the visit. But, collecting too much data reduces their ability to leverage it quickly for quality improvement.
The information must be easily understood during a time-limited visit and lead to action. To repeat the often stated mantra, “it’s about the workflow”. HealthPartners clinicians have provided feedback on what information is important to them and where in their workflow it can add value. Additionally, quality resources ensure data is reviewed from a population perspective for administrative leadership.
As we begin using the PROMs data, it’s important to observe how we’re able to transform care. There are four major categories to consider for the use of PROMs data.
• Enable the physician customize the care they provide: PROMs data, when provided real time to the physician, can help guide patient centered care. A great example of this is the PHQ-9 to monitor therapy of patients treated for depression. Obtaining the PHQ-9 prior to the visit can help the treatment team monitor therapy and adjust treatment over time. This data is integrated into the visit documentation so it’s at the clinicians’ fingertips and can then be included in post-visit medical records.
• Use at the population level for continuous quality improvement : As you look across a population, you can use PROMs data to make practice-based changes and continually improve the care you provide. For example, our orthopedic clinic utilized this data along with physicians’ observations to change how it treats patients following ankle fractures, improving their quality of life.
• Use for required state and federal government-related reporting : Quality transparency is mandated in some state and federal programs with the goal of driving improvement. In Minnesota we have the Minnesota Community Measurement project. We now incorporate PROMs data in this measurement to enhance the healthcare system in our state.
• Use to optimize patients’ care and recovery : Collecting and utilizing PROMs not only allows us to assess and track a patient’s functional, physical, and mental status, it also allows us to project a patient’s recovery following a certain procedure based on demographic variables such as age, gender, BMI, and co-morbidities.
Gathering and reporting PROMs is a team sport. Busy care teams need simple processes to gather and present information to physicians or support team members. This has led to the following high level design framework.
• Engage the patient through multiple channels such as email prior to the visit to obtain information. Tablets can be used to administer surveys during visits but should have quick interface to the EMR for use by the care team at that time.
• Paper surveys should be available but limited to minimize time consuming data entry.
• Data should be in patients’ EMR and fit within workflow. It should provide actionable data and should not require added documentation.
• Data should be incorporated into the organization reporting system (data warehouse or other) to facilitate analysis and quality improvement efforts.
• The data should be transparent to the patient including trends of patients with similar conditions.
Making this information readily available to patients is an easy way to support them in their care journey. By using PROMs data, patients can understand their progress and how it compares to the broader population’s outcomes for the same procedure.
What’s In The Future? The Value Proposition for Proms
Now that we are “minding the gap” of patient reported outcomes, we can better measure the value of care we’re delivering.
In the not so distant future, it is likely that PROMs will be used as a quality metric for reimbursement. Government agencies and payers will want to use PROMs in conjunction with other metrics to assess the value of care. Understanding how to accurately use and adjust this information will be crucial.
Eventually, transparent PROMs data could drive patients to organizations where they perceive their care will be of highest quality and greatest value. PROMs data will also be used in combination with financial data, allowing patients to compare cost of care with outcomes.
Ultimately, evaluating PROMs will help us manage chronic conditions and drive quality improvement opportunities, as well as enhance regulatory reporting, reimbursement, cost comparisons and competition among health systems.