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Exploring Patient Reported Outcomes Measures in Healthcare

Could patient reported outcomes measures be the yardstick for quality healthcare going forward?

Patient reported outcomes measures give insight into the patient experience and care quality.

Source: Thinkstock

By Sara Heath

- Patient-reported outcomes measures (PROMs) are a fledgling clinical quality measure in the healthcare industry. Designed to fill information gaps in traditional clinical quality measures, this data serves to measure how a treatment impacted a patient’s quality of life.

PROMs are “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else,” according to the National Quality Forum (NQF).

“In other words, PRO tools measure what patients are able to do and how they feel by asking questions,” the organization continued.

Industry experts developed PROMs because traditional clinical quality measures (CQMs) – the types used in reimbursement and quality improvement models – don’t always paint an accurate picture of care, according to a report in the New England Journal of Medicine Catalyst.

CQMs often capture the process of care rather than outcomes. Measures such as mortality and readmission don’t always encapsulate the scope of care and are often outside of provider control. Taken alongside traditional CQMs, PROMs offer a more holistic view of patient care, Neil W. Wagle, MD, MBA, of Brigham and Women’s Hospital, wrote in the NEJM article.

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“Patient-Reported Outcome Measures (PROMs) are powerful because they use validated questionnaires to turn a symptom into a numerical score,” Wagle said. “With PROMs, for the first time we can use numbers to describe how much a knee replacement helps someone walk or to quantify the average difference in outcome between a biologic treatment versus conventional pharmacotherapy.”

Although many industry professionals recognize that PROMs can be helpful in quality improvement projects, PROMs are not yet widely adopted. These measures are not included in any reimbursement models, nor is there a standard protocol for collecting PROMs.

However, there are some burgeoning efforts for driving PROM use throughout the industry. Between developments at the National Institutes of Health and research regarding PROM integration into clinical care, these measures may become a stalwart in patient care improvement.

PROMIS from the National Institutes of Health

The National Institutes of Health (NIH) established PROMIS – Patient Reported Outcomes Measurement Information System – in 2004 to establish a set of reliable and standardized PROMs for industry use.

PROMIS tools can be used during both research and the clinical encounter. When used during the clinical encounter, they can inform provider efforts to improve outcomes and patient quality of life.

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PROMIS collects patient data in multiple categories, including physical health, anxiety, depression, fatigue, sleep, social function, pain interference, and global health. The NIH developed questions for adult patients, pediatric patients, and pediatric proxies such as a parent caregiver.

A sample PROMIS survey might ask an adult patient whether she can walk one block on flat ground, or if she can get in and out of bed by herself. For children, these surveys might ask about performing tasks such as buttoning their shirts or playing sports that other children their age can.

The tools provided by PROMIS have served as the benchmark as more healthcare organizations adopt PROMs into their clinical workflows.

Implementing PROMs in clinical practice

PROMs were initially developed as a measure for research and trial treatments. However, healthcare professionals have recognized uses for PROMs in clinical care areas. Currently, hospital and clinical leaders are determining best practices for integrating PROMs into the healthcare encounter.

Research shows that these efforts will require stakeholder engagement. Physician goals must be aligned with researcher goals. This will create a more streamlined approach to integrating PROMs into the healthcare environment.

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Collecting PROMs also must be easy and convenient for patient access, according to Brigham and Women’s Wagle. At Partners HealthCare, the system to which Brigham and Women’s belongs, clinicians have successfully implemented PROMs for clinical quality improvement.

The success has come by putting patients at the center of their efforts, Wagle wrote.

“The patient portal is the most obvious way to collect PROMs, and it should be the cornerstone of collection,” Wagle explained. “We recommend sending out PROMs before a visit or at the appropriate interval after surgery so the patient can complete it online in the comfort of home.”

Clinicians who use PROM responses in real time will also likely see a more engaged and amenable patient.

Challenges limiting PROM adoption

Although PROMs are key for assessing the patient experience and quality of life, they are yet to be fully integrated into healthcare clinical quality measures. This may be due to the several challenges to PROM use and collection.

 “While there has been great interest in using PROs, foundational work needs to be done to address methodologic and data challenges,” NQF wrote on its website. “Efforts are currently underway to develop and test mechanisms for collecting patient-reported data.”

There are also challenges in collecting PROMs in the clinical environment and aggregating that data to assess facility quality

Technical barriers abound, Wagle said. PROM data must be electronic, and that requires a connected patient portal and interoperability with EHR data. Collecting PROMs also takes more time out of the clinical encounter, Wagle added, and presents a challenge for physicians.

“If PROMs are to be used eventually as a quality measure for reimbursement programs, we must determine how to risk-adjust for clinical and sociodemographic patient characteristics,” Wagle wrote. “Data interoperability will also be essential.”

Additionally, healthcare professionals must determine how best to administer PROM surveys to patients and collect patient answers without becoming too burdensome.

“Finally, as PROMs collection becomes more widespread, we’ll need strategies to avoid overwhelming patients with constant surveys and to reach them conveniently without jeopardizing privacy,” Wagle concluded.


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