Quantifying pain intensity and magnitude of physical limitations using patient-reported outcomes measures (PROMs) can help determine whether and how well specific interventions will lead to meaningful improvements. But routine collection of PROMs is a challenge, as evidenced by the 30 percent to 80 percent response rate generated by joint registries.
The following tips are based on lessons we learned in implementing previsit PROM collection at two arthroplasty clinics—one serving a safety-net population and the other serving a population primarily covered by private or Medicare insurance.
Choose the right PROMs
Pain intensity and magnitude of limitations are as or more strongly related to psychosocial factors as to the severity of pathophysiology. Consequently, in addition to region-specific PROMs, we administer a two-question depression screen and a global health questionnaire that assesses both physical and mental health. We chose validated measures, attempted to minimize survey burden, and tried to align with recommendations from the International Consortium for Health Outcomes Measurement and the AAOS.
The collection platform
We opted for electronic PROMs over paper forms. Paper forms are not only more labor intensive and expensive to send, but are also more likely to be incomplete, and must then be manually entered into the database or medical record. In selecting an electronic PROM collection platform, we considered our “need-to-haves” versus our “nice-to-haves.”
For example, to enable providers to review responses ahead of the visit, we prioritized sending PROMs to patients before their appointments. We felt that two-way communication capabilities were a lower priority. However, these choices should be matched to an institution’s needs.
Because we lacked a robust patient portal within our legacy electronic medical record (EMR) to collect PROMs, we chose a separate platform. Although this required providers to become familiar with a second system, we felt that—in our circumstances at the time—a dedicated PROM collection platform offered a smoother user experience for our patients.
Establish a workflow
Due to staffing constraints, our PROM collection process was managed by a research assistant rather than by clinic staff. A single person led the implementation to minimize miscommunication and reduce the need for handoffs.
If a dedicated staff member is not managing PROM collection, it is important to structure the various steps in the process. Making it clear that the clinicians value the use of PROM scores at the point of care helped the clinic staff view PROMs as a “vital sign” rather than just another questionnaire.
At the clinic that served predominantly Medicare and commercially-insured patients, the staff worked more collaboratively with the research assistant. They could direct the research assistant to patients who had checked in or were in the room and were ready for PROMs, which helped prevent delays in clinic workflow. Our experience underscores the need for “buy-in” from the staff to achieve high rates of PROM collection.
Dell Medical School experience
At the beginning of each office session, each patient’s medical history, treatments tried, prior imaging, and PROMs (when available) are reviewed during a multidisciplinary huddle. About 50 percent of Medicare and commercially insured patients and 25 percent of safety-net patients completed the PROMs in advance.
Patients who did not complete PROMs prior to their first in-person visit would complete them on a tablet in the office before seeing a provider. This enabled providers to review the scores immediately before the visit. All measures are available in English and Spanish, which cover 99 percent of our patient population.
In one year, more than 850 PROM packages were distributed to nearly 700 unique patients. On average, new patients spent less than eight minutes on a PROM package. Only a handful of patients refused to complete PROMs at all.
Patients at both offices commonly faced challenges with mobile phone or internet service and technology difficulties with the electronic platform. On the day that the mobile tablet application malfunctioned, we collected paper copies. Because the collection platform was not integrated with the EMR system, PROM scores were printed out for providers to view.
The inability to brand the software was occasionally an issue. One angry patient called the PROMs “junk” because they were branded with “Dell Medical School” instead of the clinic name that was more familiar to her. After the collaboration between the medical school and the clinic was explained, she acknowledged that she would appreciate longitudinal PROM collection as a way to measure her progress.
Barriers to previsit PROM collection at the safety-net clinic included difficulty reaching patients by email or text; some patients did not receive the message or know that it was related to their care.
Many patients ignored text messages because they came from an unrecognized number. Some patients did not realize that they had an appointment with an orthopaedic specialist, so the phone call from our research assistant asking for contact information helped to decrease the no-show rate.
Safety-net patients tended to have more literacy and technology issues when completing PROMs. Sending PROMs to patients ahead of the visit allowed them to seek aid from friends and family. Because family members would occasionally complete PROMs in the office without asking the patient for input, it was important to have a dedicated staff member on site to assist with PROM collection. As messaging around PROMs becomes better scripted to highlight the importance of hearing from the patients themselves, these issues should become less prevalent.
Medicare and commercially insured patients were generally aware they had an appointment, but were often unsure of how the PROMs were related to their visit. Engaging patients in conversation about their symptoms and PROM results helped emphasize the value of this information about their symptoms and limitations. Patients at both sites appreciated when a personalized message with each patient’s appointment date and time.
At both clinics, the comprehensive nature of the PROMs prompted providers to investigate the psychosocial aspects of a patient’s illnesses. On average, patients at the safety-net clinic had worse disease as measured by disease-specific PROMs. Both their global health scores and depressive symptoms were worse than age-matched controls.
Acknowledging the impact that pain and functional limitations can have on mental health can help validate the illness experience. These discussions engaged patients in their treatment to a greater degree and enhanced the relationships between providers and patients. The full set of PROMs provided opportunities to improve patients’ health in a comprehensive manner.
Ongoing process improvement
Using PROMs to measure health from the patient’s perspective helps inform efforts to optimize outcomes while enabling providers to be good stewards of resources. Going forward, schedulers will inform patients to expect an email or text message asking them to complete PROMs before their visit. We plan to emphasize the importance of tracking PROMs over time to increase patient participation and try to associate follow-up PROMs with virtual visits for increased convenience. This will better enable us to help our patients “get and stay healthy” rather than providing care for their musculoskeletal complaints in isolation.
Karl Koenig, MD, is the medical director of the integrated practice unit for musculoskeletal care, and David Ring, MD, PhD, is associate dean for comprehensive care, at the Dell Medical School—The University of Texas at Austin. Tiffany C. Liu, BA, is a fourth-year medical student at the Perelman School of Medicine at the University of Pennsylvania.