Implementing Patient-Reported Outcome Measures

Did you know that despite the shift to value-based reimbursements and patient-centered care that fewer than 20% of hospitals use Patient Reported Outcomes (PROs)? PROs are already a key component in the Merit-based Incentive Payment System (MIPS) in outpatient, but there has been greater resistance to implementing PROs in the inpatient space. A Health Catalyst survey of 100 clinical and administrative executives in health systems of all sizes across the country revealed that just 18 percent always use PROs to guide clinical care. That is less than every 2 in 10 hospitals.

"Patient-reported outcomes are critical to enabling healthcare's evolution away from focusing on the volume of services delivered to the value created for patients," said Paul Horstmeier, Senior Vice President of Health Catalyst. "Their use promises seismic changes not only in the way providers are paid, but how they measure success, how patients choose their doctors, and most importantly how clinical outcomes are improved. Yet with few exceptions our nation's hospitals are unprepared for the shift and need help managing this new priority within the ever-shifting field of time-intensive regulatory requirements."

An NIH study concluded that, PROs are significantly associated with clinically relevant time-to-event efficacy outcomes in clinical trials and may complement and help predict traditional clinical practice methods for monitoring patients for disease progression. So even with clinically relevant evidence and pressure from the payers, why are hospitals so slow to adopt PROs?

According to Health Catalyst, here are the top three concerns to implementing PROs

1. Time and/or financial concerns
2. Concerns of implementing PROs into clinical workflows
3. Technological barriers to adoption

According to Neil W. Wagle, MD, MBA, Partners HealthCare; Brigham and Women's Hospital, Boston, there are four issues with PROs that prevent widespread adoptions.

1. Most capture the process of care, including drawing labs or starting a medication, but fail to capture the very reason that most patients seek care, which is to improve their symptoms.
2. Current outcome measures, including mortality and hospital readmission, are important but are often multifactorial and not significantly under providers’ control.
3. Many exhibit little meaningful variation across providers and, therefore, fail to differentiate between good and exceptional care.
4. Many focus on particular diagnoses, leaving substantial gaps in our ability to measure quality across the full spectrum of care.

To implement PROs, we must engage both the patients and the practitioners. Here are some tips for both patient and practitioner engagement that we have learned from our clients, as well as, talking to patients about their experience.

Patient Engagement Tips for Implementing PROs

• Multi-Modal Collection Critical to Patient Engagement in PROs. Patient engagement starts with having simple, easy to use PRO technology that allows them to take advantage of their current technological preferences. For example, the Care Experience CRMD platform can push a PRO to a patient either via text or email in simple, easy to read font to encourage engagement and obtain higher response rates. In addition to technology, the patient has to understand what is in it for them. Patients will engage with PROs if they understand it is for symptom tracking and can see improvement over time.
• Be Mindful of the Frequency and Volume of Questions. Once you start to receive PRO data and see the benefit in care, it is natural to want to expand efforts. The key is having smart question design deployed in quick, short pulses at a frequency that doesn’t overwhelm patients. At Care Experience, we have studied question set design and deployment for over a decade and learned how to engage different audiences at the right frequency to get maximum participation.
• Involve PRO data in Care. The number one reason patients don’t give feedback is because they don’t believe that the feedback will be incorporated into care. If you are asking a patient to participate in PRO data collection, you have to communicate how that information will be integrated into their plan of care. This way the patient understands that by providing this feedback their voice is heard.

Practitioner Engagement Tips for Implementing PROs

• Use PROs to create clinical efficiencies. The number one reason for resistance to PROs is that they are concerned about money or time. Having an automated PRO system can help you save both. Shehzad Niazi, MD, a psychiatrist and internist with Mayo Clinic Jacksonville (Fla.), created a PRO questionnaire to measure patient depression and anxiety. The information gathered through the questionnaire is used to inform patient visits and has resulted in an average reduction of 15 minutes per patient evaluation, freeing up time for physicians. As a result of Dr. Niazi’s PRO program, Mayo has implemented these PROs system wide.
• Integrate data with the EHR. Resistance to the implementation of the PROs occur when there are technological barriers to adoption. When integrated properly into care, PROs can trigger alerts. James Willig, MD, an associate professor and infectious disease specialist with the University of Alabama at Birmingham, uses an electronic PRO survey to measure symptoms like depression, anxiety and suicidal ideation among HIV patients. The surveys are used to trigger a member of the clinic's psychiatry team to join patient consultations for support when appropriate.
• Ensure that PROs are clinically relevant. Practitioners want clinically relevant tools and PROs can be tremendously effective in shared-decision making, decision support and outcomes measurement. John Spertus, MD, a cardiologist at Saint Luke's Mid America Heart Institute in Kansas City, Mo., and his colleagues use quality-of-life PRO information gathered from patients, as well as data on outcomes for heart failure and stroke compiled in clinical trials. Since the program was implemented in 2002, it has resulted in changes in patient behaviors, which have subsequently contributed to a 45 percent reduction in adverse outcomes among heart failure patients.