A look at PROMIS in practice
Current trends in the healthcare landscape are shifting toward more robust, quantitative measurements of patient outcomes and provider performance. Hoping to optimize patient-reported outcomes (PROs), standardize care, and reduce costs, many healthcare providers have led the way in the collection of PROs data.

Their experiences in implementing these processes and using the data provide lessons for others. In this, the first of a two-part series, Charles A. Goldfarb, MD, from Washington University-St. Louis, shares his experiences with implementing the Patient-Reported Outcomes Measurement Information System (PROMIS ® ). In part two, Bradley J. Nelson, MD, from TRIA Orthopaedics in Minneapolis, will share his experiences, thoughts, and impressions on the collection and use of PROs at his practice.

Dr. DeAngelis: In what type of setting do you practice? Do you have a concentration within orthopaedics? How long have you been in practice?

Dr. Goldfarb: I work at Washington University in St. Louis; I am a hand and pediatric orthopaedic surgeon, and I have been in practice for 15 years. Specifically, I'm in an academic medical center with multiple site locations.

Dr. DeAngelis: How long have you and your team been collecting PROs? What system do you use and what types of data do you collect?

Dr. Goldfarb: We have been collecting PRO data for about 15 years. Two years ago we implemented PROMIS, which we use for every patient and every visit. We use Computer Adaptive Testing (CAT), and it has worked fantastically.

Dr. DeAngelis: What was the motivation behind collecting PROs and what was the impetus that moved it forward?

Dr. Goldfarb: Originally, we collected specialty-specific measures to help with research, although the data certainly provided a window to understanding clinical outcomes as well. Although the PROMIS measures will aid in our ongoing research efforts, they will also provide a better understanding of patient care and outcomes, and will address new government mandates. In the current environment, we've taken a more global approach to using PRO data.

Dr. DeAngelis: A lot of this gets down to process. If you think about your approach at the beginning, how did you collect the first measures and what factors did you consider then?

Dr. Goldfarb: We first met at the specialty level; for hand surgery, we chose a relatively general measure, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. We chose the QuickDASH measure and elected to give it to new patients only. It simply became add-on paperwork that patients filled out manually when they were completing intake forms. That information, along with their patient history, became part of their electronic medical record (EMR), but was not necessarily used and certainly did not cost us any time or effort. It was a very easy way to start familiarizing ourselves with outcome measures and using them for research purposes.

Implementing PROMIS was a huge institutional effort, and the orthopaedic department was the first to implement it. I believe other departments are going to follow suit shortly. Implementation required a rethinking of how we approached the whole process, as well as an investment in iPads and manpower. Once we decided that the department should move forward with collecting these data, we investigated how best to proceed by learning from models across the country.

We had to work with our EMR provider to enable the rapid uptake of information provided by patients via the iPads. This is what happens now: The patient arrives, checks in at the front desk, is given an iPad, completes the questions if they have time in the waiting room, and hands it back to the front desk. If the patient is immediately seen by the physician, the patient can fill it out in the exam room. As soon as the process is completed, it wirelessly connects with our EMR and it is available for the physician to review before he or she enters the room. The process is repeated at each visit. It has been a global effort and very successful. We have completion rates of more than 95 percent.

Dr. DeAngelis: That's great, Dr. Goldfarb. Have there been any particular barriers on the physician or patient side that others should be aware of?

Dr. Goldfarb: A major priority for us is limiting negative effects on the physician side; physicians have been supportive simply because it does not change their patient care process. It does put a little burden on the patients and front desk staff but, in the implementation process, we made sure it would not have an impact on physicians, so they could continue to focus on treating the patient.

We are asking patients to complete another form, but in general they have done it without complaint. I believe we are more successful in patient completion percentages than other centers. I have heard that other centers with similar processes had about a 50 percent or 60 percent completion rate, which obviously is dramatically different and really changes the utility of the data.

Dr. DeAngelis: You mentioned you are collecting PROMIS data now; what other measures are you actively pursuing?

Dr. Goldfarb: Each specialty has one legacy measure that is still collected. For hand and upper extremity, we collect the QuickDASH. We use a limited number of PROMIS modules, which include general health measures, along with anatomic-specific measures.

Dr. DeAngelis: Can you speak to the idea of using the PROs for patient safety quality improvement? Does it resonate for that purpose or is the focus more on research and clinical care right now?

Dr. Goldfarb: I think there's an opportunity to use the data to address patient safety improvements, but at this point PRO data have primarily been for research and patient care purposes. I think there is great opportunity in the patient safety realm, but we have not yet delved into it.

Dr. DeAngelis: In looking at this process, the Academy is very interested in a couple of areas, specifically the interaction/communication between the patient and physician, the impact on clinical decision making, detection and monitoring symptoms, and the length of the encounter. Have you observed any changes in these areas in either your personal practice or in the hand surgery department at Washington University?

Dr. Goldfarb: I'll address those in reverse order. Length of encounter hasn't changed. The nice aspect of PROMIS and the CAT feature of PROMIS is how quickly it can be completed. So it's not affecting overall patient time in the office and it's definitely not affecting face-to-face time between the provider and patient. I do think there is an opportunity to shorten the length of encounter, and certain providers in our practice have found that to be the case. I can certainly use the PROMIS data to engage with the patient differently and perhaps start the conversation based on the information I have prior to entering the room. That is a choice I make.

Patient care is affected in certain ways. For example, if I've seen a patient numerous times, I can get a better understanding of both general health status, mental health status, and anatomic-specific status by reviewing their PROMIS scores from a year-and-a-half ago, prior to the current visit. The data provide me with insight before I walk into the room and I think that directly affects the care I provide the patient in the short term, as well as understanding their needs and possible outcomes in the long term.

Regarding interaction/communication between the patient and physician, I don't think there have been major impacts other than generating specific questions about the process, but in general it is not mentioned by patients or physicians. The PROMIS data have not changed our patient interactions and are almost never mentioned (positively, negative, or neutrally) in the encounter.

Dr. DeAngelis: What lessons have you learned and what do you wish you had known when you started the process of collecting PRO data?

Dr. Goldfarb: The paper forms of the legacy measures such as the DASH were helpful, but only if the patients completed them properly, and this required a resource to continually check the data. The nice thing about implementing PROMIS is that it is much more streamlined, and again we are collecting data on more than 95 percent of patient encounters. We have powerful data and so the quality is high. Our ability to gain a large-scale understanding of our patient population is far superior. I believe that the more computer-adaptive testing is used, the better the data will be. As we all know, data and our ability to interpret them depend on the quality and the completeness of the data on the front end.

Dr. DeAngelis: Value-based payment models are coming our way. What are your thoughts on what orthopaedic surgeons should be doing right now and what is one piece of advice you would give?

Dr. Goldfarb: It is important to engage in this process and do so in a thoughtful way. My advice for Academy members is that value-based payments models are real and are in our future. You have to take them seriously. PROMIS has the opportunity to be a real help in this process.

Joseph P. DeAngelis, MD, MBA, is a member-at-large of the AAOS Performance Measures Committee. Neha Agrawal, MPH is the Quality & Performance Measurement Specialist in the AAOS Research, Quality & Scientific Affairs Department.