Implement for Patient Care

HealthMeasures are increasingly being used in patient care for multiple aims such as screening and monitoring change over time. Successful implementation requires a multi-step process. Use the webpages in this section to identify specific implementation tasks and guidance.

Knowing your aims for assessment (e.g., symptom management, monitor outcomes) is an important first step.

Aims for Patient-Reported Outcomes (PROs) in Patient Care

Jensen and colleagues (2015) identified five aims for including PROs in clinical practice. Knowing the aims of assessment will dictate what measures to use, when, and with whom. Ideally, one assessment can be utilized for multiple purposes (e.g., monitor outcomes of an intervention AND be included in a PRO-based performance measure for value-based health care).

  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

Questions to Clarify Aims of Assessment

  • What are the clinical goals of having direct-from-the-patient information provided from a PRO?
  • How will care change (if at all) as a result of having access to patient-provided information?
  • How will patients use information from PROs (if at all)?
  • Are there any regulatory or external requirements that would be fulfilled by implementing PROs?

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 2019 recommendations for patient-reported Functional Status Assessment Measures (FSAMs) for use in routine clinical practice in patients with rheumatoid arthritis. Learn more>>

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.

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>>