Realizing the Promise of Patient-Reported Outcomes Measures

Realizing the Promise of Patient-
Reported Outcome Measures
Our Experience at Partners HealthCare
Rachel Clark Sisodia, MD
Partners HealthCare, Boston Massachusetts
Medical Director for PROMs, Massachusetts General Hospital
Asst. Professor of Obstetrics, Gynecology and Reproductive Biology
December 14, 2017
From an original presentation by Neil W. Wagle, MD MBA

Center for Population Health | Quality, Safety, and Value
Learning Objectives
• State the value and potential use cases of Patient-Reported Outcome Measures
(PROMs).
• Use practical case examples of PROMs in action to guide deployment in your
organization.
• Construct tactical solutions to implementation barriers.

Partners HealthCare System Members
Partners HealthCare is an integrated system consisting
of the following:
• Two large Harvard-affiliated academic medical centers
(Massachusetts General Hospital and Brigham and Women’s
Hospital).
• Six community hospitals.
• Five community health centers.
• Five major multispecialty ambulatory sites.
• Inpatient and outpatient psychiatric and rehabilitation
specialty services.
• Homecare.
• More than 6,000 physicians.

Poll Question #1
If you were asked to help a family member find a hospital or doctor, how would
you do it?
a) Use publicly available quality metrics
b) Shop websites and articles
c) Use your own personal healthcare network/your PCP
d) Friends and family members
e) Use your insurance provider’s list

Partners PROMs Collection
Scaling rapidly:
• ~350,000 collections
• ~800 iPads
• ~85 clinics
Leading specialties:
• Orthopedics
• Oncology
• Psychiatry
• Neurology
• Urology
• Primary Care

7
PROMs as the Outcome Metric of Relevance
Using Variation by Provider (or Modality) to Discover Value

What we measure now
• Mortality
• Length of Stay
• Readmissions
• Lab values
• Process Measures
• Others
What else matters to Patients
• Symptoms
• Daily Activities
• Functional Status
• Mental Health
• Quality of Life
8
What aren’t we measuring?

Center for Population Health | Quality, Safety, and Value 9
Outcomes in Prostate Cancer
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
5yr Mortality Incontinence Impotence
Average Center
Best Center

Incontinence After Radical Prostatectomy
• Time period: January
1, 2014 to July 1, 2017.
• Interval represents
95% confidence
interval.
• Lower scores are
better.
• 0-2: None.
• 3-4: Mild.
• 5-6: Moderate.
• 7-12: Severe.
ExpandedProstateCancerIndexComposite
IncontinenceSubscale
One Year

Incontinence After Radical Prostatectomy
1, 2014 to July 1, 2017.
95% confidence
interval.
better.
• 0-2: None.
• 3-4: Mild.
• 5-6: Moderate.
• 7-12: Severe.
IncontinenceSubscale
Three Years

Sexual Dysfunction After Radical Prostatectomy
1, 2014 to July 1, 2017.
95% confidence
interval.
better.
• 0-2: None.
• 3-4: Mild.
• 5-6: Moderate.
• 7-12: Severe.
SexualSymptomSubscale
One Year

Sexual Dysfunction After Radical Prostatectomy
1, 2014 to July 1, 2017.
95% confidence
interval.
better.
• 0-2: None.
• 3-4: Mild.
• 5-6: Moderate.
• 7-12: Severe.
SexualSymptomSubscale
Three Years

Outcomes in Multiple Dimensions
Confidential and Peer-
Review Protected.
Do Not Distribute
Bowel Symptoms
Incontinence
Vitality
“Hormonal”
Symptoms
Urinary IrritationSexual Dysfunction

Measuring Variation  Quality Improvement
Good example: Incontinence after Prostatectomy
o Definitely an “outcome that matters most to patients”.
o Plot and compare outcomes of the faculty - looking for lowest incontinence.
o Consider case mix, technique, other possible factors.
o Manage and position the data with care: “Half full” vs “half empty”.
o Goal: Identify best practices, drive system-wide quality improvement.

Appropriateness and Efficiency
• PROMs can help surface/guide appropriateness and efficiency efforts.
• Providence St. Joseph system (Pacific Northwest): ortho replacement hardware –
outcomes vs. cost.
• The following on surgical technique from our friends at University of Rochester.
o Judy Baumhauer, MD, MPH
o David Mitten MD

Variation in
Surgical
Techniques
Courtesy of Judy
Baumhauer MD
MPH
Professor and
Associate Chair of
Orthopaedics

18
PROMs in Patient Care
Better Shared Decision Making
Happier Providers, More Personalized Care

Outcomes in Laminectomy
3 months after low back surgery at Partners
HealthCare, leg pain is reduced by half.
Leg Pain (0-10, lower is better)
Pre-Op mean: 6.8
3 month mean: 3.6
1 year mean: 4.3
p < 0.0001 at 3m and 0.0009 at 1y in matched samples

Laminectomy: Leg Pain
• Leg pain may indicate surgical
appropriateness for laminectomy
• Leg pain improves rapidly and
dramatically after surgery
• But after 2-4 months, some of the benefit
goes away.
• But there is significant sustainable benefit.
• Telling patients about this is important
to set patient expectations.
Days Before/After Surgery
LegPainScore(0-10,0isnopain)
Outcomes After Laminectomy: Leg Pain

Effect on Providers
Perhaps paradoxically, when embraced, this additional data
saves you time and enables deeper, more personalized care.
“I can’t do
one more
thing.” “There’s more
and more data;
I’m awash in
data.”
“I’m losing the
human connection
that brought me to
medicine.”
The Current Landscape

PROMs Highlights Clinically Meaningful Change

25
PROMs for Value Demonstration and Transparency
Sharing the Results with the World

Total Knee Replacement: Relief from Knee Pain
Our patients report, on average, little to no knee pain one year a knee replacement.
This graph measures the severity of your knee pain before a total knee replacement and after a
total knee replacement. A higher score means you feel better and have less pain. Most patients
see a dramatic increase in their scores from less than 40 out of 100 before surgery up to almost 90
out of 100 one year after surgery, representing very little pain. The vertical line represents the
Patients usually have
severe knee pain
before surgery.
Knee pain improves
rapidly over the first few
months after surgery …
After one year,
many of our
patients are nearly
pain free.
… and continues to
improve over the
course of a year.

Poll Question #2
Which aggregate use case is most compelling for you?
a) PROMs for individual patient care (more efficient, more personalized)
b) PROMs for shared decision making
c) PROMs for comparative effectiveness (procedure or provider) and quality
improvement
d) PROMs for appropriateness and efficiency
e) PROMs for transparency / value demonstration

31
Implementation
Technical and Operational Solutions

Steps to Implement a PROMs Program
Leadership buy-In (use other
systems’ examples to sell it).
1 2
Form Team Functions:
implementation, technology,
data & advanced analytics.
Choose a technology platform
(EHR native; integrated side-care;
third-party).
3 4 5 6
Decide on your collection
modalities (at home, in clinic,
multimodal), and get your IT
working well.
Pick an initial target
(PROMs are the outcome of relevance, clinical
and administrative champions exist
Orthopedics, CHF, Asthma, Urology).
Implementation and data
analysis: chicken or egg.
• For data to show
relevance/importance, you need
to implement.
• To implement, clinicians often
want data.
• So, start with someone who has
faith.

Agree on which PROM to Measure
, but not as hard as you might think.
Criteria
1. Short
2. Relevant to clinical care
3. Validated
4. Industry-standard (ICHOM, national registries)
5. Covered by a PROMIS domain? (Patient-Reported
Outcomes Measurement Information System)
• Emerging consensus to use PROMIS
• Free/NIH sponsored
• In Epic Foundations
• Computer Adaptive Testing
consensus is hard

Agree on Which PROMs to Measure
Criteria
1. Short.
2. Relevant to clinical care.
3. Validated.
4. Industry-standard (ICHOM, national registries).
5. Covered by a PROMIS domain? (Patient-Reported Outcomes
Measurement Information System).
• Emerging consensus to use PROMIS.
• Free/NIH sponsored.
• Computer Adaptive Testing.
Consensus is hard, but not as hard as you might think.

Poll Question #3
All of the following are mission critical, but which of the following constituencies
might be the determining factor in a successful PROMs implementation?
a) Patients
b) Staff
c) Clinicians (physicians, etc.)
d) Unsure or not applicable

Robust Collection = 3 Happy Customers and a Functioning Platform
Clinical Providers
• Don’t interfere with workflow.
• PROMs must improve individual
patient care.
• AND, provide some other benefit.
• Removing other administrative
burden is a bonus.
• Scores must be actionable.
Front-Line Staff
• Improve or minimally
impact workflow.
• Administrative champion
is key.
• Clinical providers must
communicate the
imperative.
Patients
• Must reach them in ways that
are convenient for them.
• Most important determinant:
did provider use the results?
• User-interface must be
intuitive.
• Must avoid survey fatigue.
For All, technology platform must work seamlessly: Patient portal/app, WiFi,
tablets, security, integration into EHR, real-time processing.

Things Keeping Me Up at Night
Data for non-
surgical
treatment
Risk
stratification/
Case-mix
adjustment
Sharing the
Data with
Clinicians
Patient-facing
Reports

Key Takeaways
1
2
3
4
5
PROMs are the outcome metric
of relevance for many of the
conditions we treat.
PROMs can help us take faster,
more systematic, and yet more
personalized care of our patients.
It also helps with improved
shared decision making.
PROMs can be used for quality
improvement and value
demonstration at a system level, as
well as to support appropriateness
and efficiency. Implementation is challenging but
feasible with the right approach.
Challenges remain, but
progress is rapid.

Realizing the Promise of Patient-Reported Outcomes Measures

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Realizing the Promise of Patient-Reported Outcomes Measures

Similar to Realizing the Promise of Patient-Reported Outcomes Measures (20)

More from Health Catalyst

More from Health Catalyst (20)

Recently uploaded

Recently uploaded (20)

Realizing the Promise of Patient-Reported Outcomes Measures