Applications in Evaluating Quality of Care

Patient-reported outcome (PRO) measures can be used to improve the quality of healthcare services and to track or report on the performance of healthcare providers and healthcare delivery organizations.


Healthcare quality is measured and reported in a variety of ways, using established and approved reporting measures. HealthMeasures PRO tools can be used as components of measures to evaluate quality of care. PRO-based performance measures are referred to as PRO-Performance Measures, or PRO-PMs.

PROs versus PRO-PMs

  • A PRO (patient-reported outcome) is defined as any information on the status of a patient’s health obtained directly from patients, without modification by clinicians or other health care professionals. A short form quantifying level of depressive symptoms is a PRO. Sometimes PROM is used for patient-reported outcome measure.
  • A PRO-PM (a PRO-based performance measure) is an aggregate of the patient-reported information in a reliable, valid measure of the quality of care delivered. For example, a PRO-PM could be the percentage of patients starting a new treatment for cancer that were screened for depressive symptoms.

Process and Outcome Measures

Healthcare quality reporting measures are typically divided into “process” and “outcome” measures.

  • Process measures assess the extent to which a provider performs an activity that is typically associated with a good outcome. Examples of process measures are the proportion of providers conducting foot exams in diabetic patients, recommending or prescribing an indicated treatment for a given condition, or administering a PRO in clinical practice. Providers that score highly on process measures are likely to have better health outcomes than those that score poorly on process measures, but this assumption is not tested.
  • Outcome measures of health care quality performance actually examine end results, or health outcomes. Some outcome performance measures are derived from patient report, such as the proportion of patients reporting a specified level of experience of care, level of self-reported depression, degree of physical function, pain, or sleep.

While both types of measures offer important insights, payers such as Centers for Medicare and Medicaid Services (CMS) and healthcare quality leaders such as the National Quality Forum (NQF) are advocating for more outcomes-focused measures.

HealthMeasures as PRO-PMs

PROMIS® is currently being used and evaluated for use by organizations as PRO-PMs. For example, the PROMIS Global Health scale is included in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) model. Such use is likely to become more common as PROMIS and other PROs are increasingly integrated into electronic health records, registries, and routine practice workflow.

In 2017, RAND Corporation demonstrated validity of the PROMIS-29 profile with older adults with multiple chronic conditions. They then explored the challenges in developing a PRO-PM for this population including the relative stability of health-related quality of life and need for a longer follow-up period and large sample size. Learn more>>

PROMIS Depression Measures in HEDIS

The National Committee for Quality Assurance (NCQA) has added PROMIS Depression to the Healthcare Effectiveness Data and Information Set (HEDIS) 2018 measure set. Specifically, PROMIS Depression measures for adolescents and adults can be used to screen for depression. Users report the percentage of patients age 12 and older who are screened for depression with a standardized tool, and if screened positive, receive follow-up care. For more information, download the HEDIS 2018 Volume 2 Measures for Electronic Clinical Data Systems. HEDIS measures are used by more than 90% of health plans to assess the quality of care.

Demand for PRO-PMs

Efforts to contain healthcare costs, maximize clinical quality, and improve the patient experience are driving new approaches to measuring value. Quality measures in health care have traditionally focused on the actions or perspectives of the clinician (i.e., processes of care, chart-based clinical outcomes, and clinician-provided ratings on domains such as pain). Traditional healthcare quality measures are often designed around specific diseases or time points in the care process and, thus, often fail to capture relevant outcomes that patients experience across diagnoses and stages of care. Key healthcare stakeholders –including payers, professional medical societies and regulatory agencies—are now calling for the development of PRO-PMs that will incorporate the patient voice into quality measures and provide a more complete picture of care quality.

PRO-PMs Development

Healthcare quality measures, including PRO-PMs, are developed by:

  • Government agencies (e.g., CMS)
  • Professional and medical associations
  • Private nonprofit and for-profit organizations

CMS outlines a lengthy process (the “measure lifecycle”) through which performance measures are developed, evaluated, endorsed, and maintained. Feedback and commentary from patients and families, healthcare professionals, and the general public are interwoven throughout this measure lifecycle. Potential quality measures are often endorsed by nonprofit organizations such as the National Quality Forum (NQF). These organizations bring together stakeholders to review proposed measures against pre-established standards, including its psychometric soundness, person-centeredness, relevance to patients and providers, and feasibility of implementation. Learn more>>

Next Steps in PRO-PM Implementation

Several obstacles must be addressed to realize the full potential of PRO-PMs in evaluating care. For example, selection of PROs is needed. Some measures were developed for specific patient population (e.g., KOOS for knee osteoarthritis) and other measures were developed to be used across conditions (e.g., PROMIS Physical Function). Universal measures can minimize redundant assessment, facilitate comparisons, and avoid undue patient/provider burden but may not always include critical aspects of a symptom or function for a specific condition. Identifying what measures for what patients is an area of active research. A second obstacle is how to best utilize a PRO in a PRO-PM. When are process measures (e.g., percentage of patients with cancer screened for emotional distress) most appropriate and when are outcome measures (e.g., percentage of total knee replacement patients with physical function surpassing an identified threshold) most appropriate? In addition, many providers have called for risk adjustment strategies that will enable PRO-PMs to fairly evaluate providers who care for sicker patients or who deliver care in low-resource settings. New areas of PRO-PM research include:

  • Risk-adjustment strategies
  • Studies confirming the clinical relevance of PRO-PMs
  • PRO-PMs as means of measuring patient engagement, patient activation, and the quality of shared decision-making.

Learn More

Read the Blueprint for the CMS Measures Management System>>

CMS describes the Blueprint as “the core set of business processes and decision-making criteria for [healthcare quality] measure development” that can be “a helpful resource whether your interest is in developing measures or in understanding the measure development process.”

Read RTI's Patient-Reported Outcomes in Performance Measurement>>

RTI International published a book in 2015 titled Patient-Reported Outcomes in Performance Measurement for a discussion of the major methodological issues related to the selection, administration, and use of PROs for individual patients in clinical practice settings, including those aiming to integrate patient-reported outcomes into a quality improvement/performance measurement program.

Read National Quality Forum’s 2013 Report on PRO-PMs>>

NQF outlines the guiding principles for PRO-PM development and describes the pathway from PRO to PRO-PM. It includes the NQF endorsement criteria and approach to evaluation of a PRO-PM for endorsement.

Read more about PRO performance measures in oncology>>

To learn about PRO performance measures in oncology, see Basch E, Snyder C, McNiff K. Patient-reported outcome performance measures in oncology. Journal of Oncology Practice. 2014:10(3):209-211.