Measuring Success: Implementing Patient-reported Outcome Measures Into Your Practice
By: Kevin W. Wilson, M.D.
The concept of the patient-reported outcome measures (PROMs) has migrated from the background, based in research, to common discussion in everyday clinical practice. Rather than relying on imaging, simple exam measurements and the surgeon's assessment of return of strength and function, PROMs give the patient a stake in how we evaluate the results of any intervention.
The growth and development of incorporating PROMs in orthopaedic practice has mirrored the use of big data and other industries, including professional sports. Larger corporations are leveraging their resources to incorporate these techniques, while smaller entities are taking more measured approaches. While most surgeons can agree that an accurate measurement of the patient's perception of their success in treatment is vital, how we collect and utilize this data remains highly controversial. Furthermore, the push for pay-for-performance in health care creates many concerns for the frontline surgeon wondering how to implement meaningful PROMs in a variety of clinical settings. The experiences of AANA members from large academic centers, military institutions and group practices have recurring themes. Most agree that there is tremendous promise and importance in measuring patient-reported outcomes.
Louis McIntyre, M.D., past president of AANA and Chief Quality Officer at U.S. Orthopedic Partners, works to implement patient-reported outcome programs across partner practices. He advocates that PROMs are useful in quality control (value equals outcome/cost), compliance (merit–based incentive payment system), negotiating, marketing, patient engagement, research and alternative payment methodologies like bundled payment programs. He states that these measures can identify or confirm clinical deficiencies and trends across practices, as well as demonstrate safety quality and efficacy. However, he also notes that there are barriers, including the cost of outcome platforms; difficulties with integrating into existing electronic medical records and practice management platforms; patient compliance; and disruption of office workflow.
Larger institutions and academic centers may have a distinct advantage in implementing these outcome measures due to the financial and information technology infrastructure resources available for implementation into system-wide electronic medical records. At the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, Albert Lin, M.D., Associate Chief of Sports Medicine, routinely uses built-in platforms in the medical record to collect and analyze a variety of outcome scores.
Dr. Lin states, "As an academic surgeon, my opinion is that capturing this type of data allows us to not only monitor outcomes but also assess durability of treatments. This data is valuable for research and it ultimately provides us with information to improve the value of care delivery to our patients." He goes on to say that simple scores such as a visual analog scale or subjective shoulder value are exceedingly helpful on a day-to-day basis. "These simple numbers are a quick way for me to put objective data on subjective complaints, and often help me decide how much symptoms are affecting the patient, whether the patient is on the right track or whether we need to alter the treatment."
Dr. Lin also notes several roadblocks to maintaining good patient-reported outcome data, even at larger institutions. Ancillary support is needed to collect and organize registry data with fidelity and to help ensure timely patient compliance.
AANA members throughout the U.S. military have made major strides in implementing a comprehensive data capturing system entitled, "Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION)." The primary objective of the MOTION initiative is to establish a military health system-wide solution to capture and evaluate clinical and patient-reported outcomes for operative and nonoperative musculoskeletal injuries. As MOTION integrates into a new DOD-wide electronic medical record, the fully merged data-capturing tool will provide improved patient-centered care though real-time feedback, individual patient progress and outcomes monitoring. As of October 2020, 12 military treatment facilities have enrolled over 12,000 patients who are scheduled for surgical procedures. In the long term, MOTION-collected data may allow military health care leaders to identify clinical practice trends and assess value in musculoskeletal injury management.
Jonathan Dickens, M.D., COL, Chief of Sports Medicine and Vice Chair of Research at the Uniformed Services University Department of Surgery, has been integral to the development of the MOTION program. Dr. Dickens stresses that the shared prioritization of patient-reported outcomes across the military orthopaedic community, emphasis on value-based care and collaborative research interests led to tremendous success within a large health care setting. He also notes that "buy-in from surgeons ultimately leads to improved patient compliance, because surgeons are more apt to communicate the importance of completing the PROMs." The hope is that as more complete data sets become available, normative trends and outcomes can be determined for various procedures and disease conditions. "The clinical utility will be to show the patient where they are in their recovery trajectory as well as give the surgeon real-time objective feedback on how the patient is doing and how the surgeon is doing," Dr. Dickens adds. In order to facilitate information sharing, Dr. Dickens looks forward to significant development in the interfaces with the electronic medical record mechanism to easily display this type of data for the surgeon and the patient.
Smaller group and hospital-based practices can look to commercial systems to help with the implementation of capturing PROMs and subsequently analyzing and displaying this data in a meaningful way. In 2015, AANA launched a member benefit that gives members access to Arthrex's PROM platform, Surgical Outcomes System (SOS™). Despite advances seen with these commercial systems, integration into the electronic medical record and office workflow remain a challenge. In addition, methods to improve patient compliance is an ongoing process to ensure fidelity within the data sets.
The unifying theme from the experiences of Drs. McIntyre, Lin and Dickens is the importance of keeping it simple when launching any initiative within your practice to capture PROMs. Dr. McIntyre recommends that you should, "choose an outcomes platform and one surgical procedure to start. Identify one staff member, such as a medical assistant, to manage the program and aim for 70% compliance." With any success, Dr. McIntyre recommends migrating to other procedures and nonoperative care pathways. Dr. Dickens agrees, saying that, "the more simple and universal you can make it, the more successful it can be implemented." Dr. Lin adds that the key to buy-in from patients is allowing them to understand that, "the information collected is not just for research; it will also influence the care provided to them, their family and their friends."
While implementing a system to capture PROMs may be daunting, both the promise and the problems seem to be universally recognized. Surgeon collaboration through organizations such as AANA will undoubtedly lead to improved means of measuring our patients' perspectives and successful interpretation and utilization of this data.