Publications

New study aims to facilitate the implementation of patient-reported outcome measures

In a case study published in Health Policy Volume 125 issued in September 2021, researchers from the Netherlands highlighted the conductive elements and obstacles to the implementation of patient-reported outcome measures (PROMs). The study was conducted in the Erasmus Center, a hospital with a leading position in PROMs, and is titled “Facilitators and barriers for implementing patient-reported outcome measures in clinical care: An academic center’s initial experience”.

What are patient-reported outcome measures (PROMs)?

Patient-Reported Outcome Measures (PROMs) have gained importance in healthcare, as part of the quest towards more value-based/value-driven systems. PROMs are feedbacks from the patient on their health status (e.g. wellbeing, symptoms) and/or treatment, without external interpretation by professionals. They can be used to monitor the development of a patient’s symptom burden and quality of life over the course of the disease and/or treatment, facilitate patient-provider communication, enhance shared decision-making, examine the quality of care, conduct comparative effectiveness research, and also in value-based payment systems.

Study settings

The Erasmus University Medical Center, a large academic healthcare institution in Rotterdam, the Netherlands, started a value-based health care (VBHC) strategy in 2013. This initiative included the definition of standardized outcome sets (including both provider- and patient-reported outcomes), and the development of a collection tool to trace them. These sets were developed by the International Consortium for Health Outcome Measurements (ICHOM). Since the end of its pilot phase (2015-2019), the VBHC-concept has been successfully implemented for several conditions including breast cancer, cleft lip and palate, stroke, familial hypercholesterolemia, and Turner syndrome.

However, other disease teams did not yet succeed in implementing the collection of PROMs on a routine basis, and many other healthcare organizations have had mixed success in implementing routine use of PROMs in a clinical setting. This study aimed to provide them with insights from healthcare providers and researchers in a large academic hospital on the facilitating and hindering elements to the implementation and use of PROMs.

The study

The study was conducted via a questionnaire addressed to healthcare providers and researchers across multiple medical departments involved in a value-based health care initiative in the hospital. The questionnaire statements were rated using a 5-point Likert scale ranging from “strongly agree” to “strongly disagree”, and 8 open-ended questions allowed respondents to mention additional facilitators and barriers.

Findings

The 61 participants were from both surgical and non-surgical departments and members of teams that were at different stages in their PROMs implementation. Frequently reported facilitators were the presence of a PROM coordinator in the outpatient clinic (85%), the integration of PROMs in patient’s electronic health record (81%), and the motivation of professionals involved in the implementation (N=9 open responses). The commonly reported barriers were language (76%), IT issues (N=17 open responses), and time constraints (N=14 open responses).

Most respondents (89%) agreed that the purpose of implementing PROMs was clear and 63% found the administered PROMs to be relevant for their patient population with an acceptable number of questions. The majority of respondents also answered that open communication was possible within their disease team when providing feedback on the PROM implementation process. Moreover, 59% of respondents reported that reviewing PROMs prior to a consultation and discussing them during the patient encounter, made the consultation more efficient. Most respondents declared that they were open to changing their usual work routines and 88% of respondents were confident that with the use of PROMs, they would be able to provide better care for their patients. Moreover, 76% reported a willingness to use them in the future. The majority of respondents were unafraid that the quality of their care might be assessed based on PROM results and 81% of respondents said that the integration into the electronic record facilitates the use of PROMs. Most also reported a digital dashboard to be necessary for the consultation room with patients (79%).

On the negative side, 76% of respondents found a language barrier -for patients with a primary language other than Dutch- to be an obstacle to PROMs’ implementation.

The answers to questionnaire statements and open-ended questions showed that respondents experienced open communication about the PROMs within their disease team. This seems related to the factor “intrinsic motivation/enthusiasm/interest”, the only factor that was reported as a facilitator across almost all implementation stages.

“Multidisciplinary collaboration” within a team was also mentioned as a facilitator, as was “teambuilding around one disease/condition”. Correspondingly, “different motivation levels within the disease team to use PROMs” and “challenging multidisciplinary cooperation due to conflicting interests, schedules, and task division” were cited as experienced barriers. Healthcare professionals need to learn to work together in a multidisciplinary manner, exploring the boundaries of each other’s disciplines, being open to other insights, raising mutual trust, and creating a sense of joint responsibility.

Other facilitators reported by healthcare professionals were “better preparedness with more information on how patients are doing prior to consultation” and “more structured/ efficient patient-provider communication”.

Additionally, the “involvement of patients in their own care” was also reported as a facilitator. These suggest that engaging patients in their own care process seems to incentivize healthcare professionals to implement PROMs in clinical care, which may lead to a more individualized health service and an improvement in the quality of care.

The presence of a PROM coordinator in the clinic was a frequently reported facilitator, while its reverse, “the absence or lack of staff for coordination” was also a reported barrier. This factor may be related to other barriers that were frequently reported, namely “time constraints and/or the “labor-intensive nature of the implementation”.

Issues related to the IT infrastructure were also frequently cited as a barrier, with respondents reporting difficulty in accessing the PROM platform, its slow working speed, the visually unappealing dashboard, and the lack of integration in the patient’s electronic record.

Conclusions 

For the successful implementation of PROMs in clinical practice, healthcare organizations should consider supporting motivated healthcare professionals, involving PROMs coordinators, and investing in an adequate IT infrastructure. As one of the potential benefits of PROMs is the discussion of patient issues that otherwise would not have been identified, the availability of PROMs in multiple languages may be an effective and relatively inexpensive way to work towards healthcare equity by taking into account the needs of non-native speakers and patients with low health literacy skills.