Patient-reported outcome measures (PROMs) have become more common over the past 30 years. Providers have been exposed to PROMs through the reporting of performance measures for the Physician Quality Reporting System and payment reform efforts such as the Merit-based Incentive Payment System track in the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA). Some providers may also participate in registries—such as the National Spine Network or the American Joint Replacement Registry—that aggregate patient-reported outcomes and provide comparisons to national averages. Fewer providers are familiar with the use of PROMs immediately prior and during an appointment to adjust the care delivery process.

Types of PROMs
PROMs can be classified in two basic categories: general health and condition-specific. General health surveys gather a patient's perspective on his or her overall health status and sense of well-being. These general health surveys can have limited usefulness in detecting meaningful changes in a specific disease state, while condition-specific surveys may miss unintended consequences and changes in comorbid conditions. For example, a condition-specific back pain and disability questionnaire may closely monitor a patient's self-reported ability to sit, stand, walk, and lie down, but would miss aspects of emotional well-being and mental health status.

For these reasons, experts typically recommend using both types; however, it can be possible to use just one depending on the condition and the selected survey. Psychometricians have begun interviewing patients and using patient focus groups to identify concepts that matter to patients to create surveys that assess the identified concepts. Surveys created this way are not only patient-centered and patient-reported the survey items themselves are patient-generated.

Research, reimbursement, and point of care
MACRA prioritizes the development and use of patient-reported outcome performance measures (PRO-PMs) along with other types of outcomes, including patient experience, care coordination, and appropriate use. The QPP is focused on moving the payment system to reward high-value, patient-centered care. A provider's Medicare payments will be adjusted up, down, or not at all depending upon the quality measure data submitted. For this reason, providers have sought feedback about their scores. The feedback has been provided on annual, semi-annual, or quarterly bases. Overall, the usefulness of the feedback has been disappointing. Due to the delay between the provision of care and the receipt of the feedback, the experience has been likened to trying to cross a busy street blindfolded and based on a photograph of traffic taken 6 months earlier.

Using PROMs at the point of care is not yet common, in part because the steps involved are more difficult than first imagined. Building and maintaining a web portal or application is not easy. How the surveys are delivered and displayed to patients and how the results are delivered and displayed to care providers are also topics of concern. Perhaps most importantly, few providers have been trained on how to integrate the additional information.

Some organizations that have persisted have reported substantial improvement to care processes. Among these facilities are a New England-based multidisciplinary spine center that began using PROMs in the late 1990s and a Florida-based diabetes specialty care group that began in the 2010s. Both have interesting lessons.

The spine center found a surprisingly large proportion of patients with very low self-reported mental health scores. Although the center employed a behavioral health specialist, fewer than 10 percent of the patients with low scores received a referral to the specialist. However, the referral rate eventually approached 90 percent after the center created an automatic text message to the specialist for patients with self-reported mental health scores below a validated threshold. After receiving notification, the specialist would meet the patient in the waiting area and escort him or her to an exam room where a discussion could begin regarding the patient's status. This application of the survey helped in two ways. First, it improved screening of patients for symptoms of anxiety and depression. Second, it increased the referral rate to care that is known to be effective for those symptoms.

The experiences of the diabetes group also provide lessons for orthopaedic surgeons. Patients in the Florida facility were asked to rate how overwhelmed they felt about everything they needed to do in following care instructions. Patients with scores indicating they felt "overwhelmed" were questioned specifically about the source of their feelings.

The diabetes group soon found the question very useful because it helped to improve adherence to treatment regimes. Eventually, the group adapted the following standard:

• The provider first shared the survey results with the patient and said: "Thank you for filling this out. It helps us treat you better. Please tell me more about this score, here, that is about feeling overwhelmed. What is it that is causing you to feel this way?"
• After sharing the survey results and having the conversation, the provider and the patient jointly formed a new plan.
• At this point, the provider would review the new plan and ask how confident the patient was in his or her ability to carry out the plan. The provider assessed the patient's confidence by saying: "Now with this new plan, how confident are you about your ability to do it? Zero equals no confidence at all and 10 equals completely confident."
• Any response from the patient that was less than an 8 out of 10 was followed up with the question, "What would you need to improve your confidence to an 8 or higher?"

The new care process helped providers to identify patients who were overwhelmed, and therefore at risk of low adherence to treatment protocols. They could then jointly design new treatments that the patients were more confident about following. Preliminary results suggest more patients are better adhering to treatment plans and demonstrating improved clinical outcomes.

Summary
Although many providers consider Medicare as the primary reason for their use, commercial payers are increasingly adapting a similar approach to payments. Because PROMs will be tied to reimbursement, orthopaedic practices will benefit from creating processes that enable their use at the point of care to identify what matters most to patients and to align more quickly the care provided with the patient's needs.

Thom Walsh, PhD, is founder and chief strategy officer of Cardinal Point Healthcare Solutions, an adjunct faculty at the Dartmouth Institute for Health Policy and Clinical Practice, and author of Navigating to Value in Healthcare.

Using PROMs in Practice
Steps to ease data collection and make patient-reported outcome measures actionable in your practice include the following:

• Select a combination of general health and condition-specific measures. Note that AAOS sought specialty society input to compile "The Instruments for the Collection of Quality Data," a consensus recommended list of regional, anatomical and diagnosis specific PROMs. Access that list here.
• Explore options for capturing patient-reported data prior to the appointment via a web-based patient portal or app.
• Consider using screening questions for anxiety, depression, or feeling "overwhelmed" to identify patients at high risk for poor outcomes.
• Develop an office flow that uses the measures to inform treatment decisions.

References:

1. Walsh T, Hanscom B, Lurie J, Weinstein J: Is a condition-specific instrument for patients with low back pain/leg symptoms really necessary? Spine 2003;28(6):607–615.
2. Weinstein J, Brown P, Hanscom B, Walsh T, Nelson E: Designing an ambulatory clinical practice for outcomes improvement. Quality Management in Health Care 2000;8(2):1–20.
3. Walsh T, Hanscom B, Homa K, Abdu W: The rate and variation of referrals to behavioral medicine services for patients reporting poor mental health in the National Spine Network. Spine 2005;30(6):154–160.