Patient-reported outcome measures: Routinely collected, but rarely used in clinical care

Even when patient-reported outcome measures (PROMs) are successfully incorporated into electronic health records (EHRs), these patient-centered data are infrequently accessed by members of clinical care teams, suggests a study in the November/December issue of American Journal of Medical Quality.

At one large orthopedic practice, care teams accessed PROMs data for less than 1% of visits by patients undergoing total knee or hip replacement surgery, according to the report by Jeanette Y. Ziegenfuss, Ph.D., of HealthPartners Institute, Minneapolis, and colleagues. They write, "Making PROMs available for care team review in the EHR...is not enough to encourage integration of PROMs into clinical care for patients."

Why PROMs data is important in patient care

A key focus of efforts to measure healthcare quality, PROMs are designed to capture data on outcomes important from the patient's perspective—for example, daily functioning, quality of life, and experience of care. Data from PROMs have mainly been used for public reporting of system-wide outcomes or quality improvement initiatives. Few studies have evaluated whether and how PROMs are being used to inform everyday patient care.

As part of a larger project at a Midwestern health network, the study orthopedic department made an investment to integrate PROMs into the electronic health records (EHRs). Starting in 2017, the clinic began collecting PROMs data on all patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA), including assessments of joint function, general health and functioning, and patient satisfaction.

How was this information used at the point of care? To find out, Dr. Ziegenfuss and colleagues analyzed how often the PROMs data included in the EHR were accessed by orthopedic surgeons and other members of the care team for patients undergoing TKA or THA over a 15-month period in 2019-20.

Though readily available in EHRs, clinical use of PROMs data is 'nearly non-existent'

The analysis included data on 2,400 TKAs performed by 22 surgeons and 1,545 THAs performed by 20 surgeons. Most patients completed the PROM questionnaires, with response rates ranging from 68% before surgery to 55% at 12 months' follow-up.

However, in over 16,000 care encounters associated with these surgeries, clinicians viewed PROMs data in the EHR just 156 times. The patient ratings were accessed by care teams for 0.9% of clinical encounters.

The PROMs data views were "largely clustered by surgeon"—just 4 surgeons accounted for more than three-fourths of views. For most patients, the PROMs data were never accessed as part of clinical encounters.

Thus, while survey response rates were relatively high and the data was successfully integrated into the EHR, "the use of these PROMs data among surgeons and care teams was nearly non-existent...suggesting that a critical step in the pathway to the promise of using PROMs to improve the individual patient encounter was not being realized," Dr. Ziegenfuss and colleagues write.

The researchers note that their analysis was limited to two types of surgeries in a single department. However, they also point out that their project may represent a "best-case scenario" for clinical use of PROMs data—carried out in a setting with a long history of supporting measurement and quality reporting.

"If the use of PROMs for clinical care was not taken up here, this problem might be even more likely to be present in other systems without these supporting factors," Dr. Ziegenfuss and coauthors conclude. They highlight the need for "[a]dditional effort...to identify barriers to PROMs use in clinical care and to test methods to enhance use."

Coauthor Megan Reams, Director of Orthopedic Research & Education, TRIA Institute, notes, "As a health system, we recognize the importance of this work and are excited to bring the patient-reported outcome data into our electronic medical record and continue to find ways to optimize engagement of our clinicians in use of this information as they care for our patients."