Applications in Clinical Practice

HealthMeasures are increasingly being used in clinical settings. They provide clinicians with efficient, reliable, and valid assessments of adult and child health, including function, symptoms, feelings and perceptions.

Integrating Patient-Reported Outcomes into Electronic Health Records (EHR)

The National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) awarded $6.3 million to a coalition of nine universities, led by Northwestern University.

 

  • Project will integrate self-report HealthMeasures in electronic health records to improve clinical care and research
  • Integration will include Epic, Cerner, and SMART on FHIR

 

Read the full press release here>>

Aims for Patient-Reported Outcomes (PROs) in Clinical Practice

Jensen and colleagues (2015) identified five aims for including PROs in clinical practice.

  1. Needs assessment (e.g., screening for depression)
  2. Shared decision making (e.g., expected functional improvement from total knee replacement versus physical therapy)
  3. Symptom management (e.g., monitoring unexpected adverse effects from chemotherapy)
  4. Outcomes assessment (e.g., regular assessment of fatigue after starting a new treatment)
  5. Quality improvement (e.g., symptom prevalence within a health system)

Jensen R.E., Rothrock N.E., Morgan DeWitt E., Spiegel B., Tucker C.A., Crane H., Forrest C.B., Patrick D.L., Fredricksen R., Shulman L.M., Cella D., Crane P.K. (2015). The role of technical advances in the adoption and integration of patient-reported outcomes in clinical care. Medical Care, 53, 153-159

 

Evidence Supporting Routine Collection of Patient-Reported Outcomes (PROs)

There is a growing body of evidence on the impact of routinely collecting PROs (like those in PROMIS®, Neuro-QoL, ASCQ-Me®, and NIH Toolbox® Emotion) in clinical practice.

  • A 2013 systematic review of this literature found three benefits of the clinical use of PROs: improved patient-provider communication, patient satisfaction, and detection of unrecognized problems. The evidence has not accumulated for the impact of PROs on changes in patient management, patient behavior, health outcomes, nor improvement in quality of healthcare.  Learn more>>
  • A 2015 review confirmed the finding that routine collection of PROs in cancer clinics improved communication about symptoms and quality of life.  Learn more>>
  • That was further supported by a review of studies of collecting patient- and caregiver-reported outcomes in palliative care settings and sharing results with providers. The authors found strong evidence for increased reporting and recognition of symptoms, improved patient-provider communication, and clinicians taking more actions (e.g., referrals) in response to scores. Learn more>>
  • A 2016 study at Memorial Sloan Kettering Cancer Center found that patients with advanced cancer who completed PROs on 12 common symptoms had “better health-related quality of life, fewer ER visits, fewer hospitalizations, a longer duration of palliative chemotherapy, and superior quality –adjusted survival” (p. 562). A 2019 study with a similar intervention with patients with lung cancer also found increased survival.  Learn more>>
  • A systematic review of randomized controlled trials that used a PRO measure as an intervention included 22 studies published between 1989 and 2016. Most studies compared collection of PROs followed by sharing scores with the care team to collection alone. Some of these studies noted improvements in process of care, health outcomes, and satisfaction with health care. A minority of studies compared collecting a PRO to not collecting a PRO and these were generally less likely to see a change in process of care, health outcomes, or satisfaction with health care. The authors noted frequent failure to pre-specify expected intervention outcomes and adequately power a study. Learn more>>

HealthMeasures Are Included in Clinical Guidelines

  • The North South Wales Agency for Clinical Innovation published a report on using patient reported outcomes in the integrated care context. Based on a 2013 review, PROMIS measures were included in a recommended short-list of PRO measures. The report states, “After review of the evidence there was strong evidence to support PROMIS.”  Learn more>>
  • PROMIS measures are included in The American College of Rheumatology’s 2015 Guidelines for the Treatment of Rheumatoid Arthritis.

 HealthMeasures Are Included in Certification Examinations

The American Board of Surgery (ABOS) requires that orthopedic surgeons submit patient-reported outcome measures as part of certification. As part of the Part II oral exam, surgeons present on 12 cases. In advance of submitting materials for the Part II oral exam, the surgeons’ patients are asked to complete PROMIS Physical Function and Pain Interference measures via the Assessment Center API at the time of surgery, 6 months later, and 1 year later. The goal of collecting PROMIS measures for these surgeons is to provide them additional information to evaluate their cases and eventually to affect care.

 A Framework to Evaluate the Implementation of PROs in Clinical Practice

In a 2018 review, Anatchkova and colleagues utilized the 2015 ISOQOL User’s Guide for Implementing Patient-Reported Outcomes Assessment in Clinical Practice to create a framework for evaluating publications on the implementation of PROs in oncology clinical practice. In their systematic literature review, they reviewed 36 publications, most of which (n=29, 81%) were reports on intervention or feasibility research. Only three studies described ongoing routine PRO assessment to manage patient care outside of the scope of a research study. Aims for PRO collection were varied including improving symptom monitoring, patient-provider communication, patient-centeredness of care, and quality of care. Only about half of the studies reported intervention results on patient outcomes. The authors also reported a need for guidelines for interpreting PRO scores and for strategies to address concerning PRO scores “…particularly when the identified needs of patients extend beyond the expertise or training found in a routine oncology clinical practice such as depression or lack of social support.” Learn more>>

Learn how PROMIS computer adaptive tests (CATs) can improve patient care.

Read J. Baumhauer’s 2017 Perspective article in The New England Journal of Medicine>>