Integration of Patient-reported Outcomes in a Total Joint Arthroplasty Program at a High-volume Academic Medical Center

Abstract

Introduction: Despite widely appreciated barriers to successful clinical implementation, the literature regarding how to operationalize electronic health record-integrated patient-reported outcomes (PROs) remains sparse. We offer a detailed summary of the implementation of PROs into the standard of care at a major tertiary academic medical center. Methods: Collection of four Patient-Reported Outcomes Measurement Information System computer adaptive tests was piloted in a large academic orthopaedic surgery ambulatory clinic starting in October 2016. The Patient-Reported Outcomes Measurement Information System computer adaptive tests (Physical Function, Pain Intensity, Pain Interference, and Ability to Return to Social Roles and Activities) were initially implemented as manual order sets to be administered before surgery through 2 years after surgery. Completion rate over time, mean time to completion for all PRO domains, and the overall distribution of symptom severity were used to evaluate the success of the pilot. A subsequent optimization and redesign of the pilot was conducted using tablets, automation of questionnaire deployment, and improved results review to address obstacles encountered during the pilot phase. Results: Two thousand nine distinct joint arthroplasty patients (mean age = 65) completed at least one set of PRO assessments, with overall completion rates reaching 68% and mean completion time of 3 minutes. Focal points during the implementation process included engagement and training of staff, selection of an appropriate patient population and outcome measures, and user friendly data displays for patients and providers. Conclusion: Our pilot program successfully demonstrated that PROs can be administered, scored, and made immediately available within the electronic health record to patients and their providers with minimal disruption of clinical workflows. Although considerable operational and technological challenges remain, we found that the implementation of PROs in clinical care within an ambulatory practice at an academic medical center can be achieved through a constellation of several key factors.

Electronic health record–integrated approach for collection of patient-reported outcome measures: a retrospective evaluation

“…Our most notable challenge was increasing our overall response rate for PROMs collection; our rate for all patients (29%) was consistent with the statistic for general surveys (33%) [ 28 ], and our rate was slightly higher for patients who were MyChart active (42%). The variation we reported in our study is consistent with other PROMs collection initiatives reported in orthopedics (34–77% over a 1-year period [ 20 ]. However, the general response rate for PROMs collection initiatives in orthopedics appears to hover around 70–80%, with studies reporting 74.9% [ 29 ] and 72.6% [ 30 ], and the UK National Joint Registry reporting 64%, the Swedish Hip Arthroplasty Registry 79%, and the New Zealand Joint Registry 70% [ 31 ].…”

“…The decision-making process and challenges we faced with our initiative are similar to other studies reporting the implementation of PROMs collection. With our implementation approach we were able to successfully administer, collect, and report PROMs within the EHR and through data visualization applications as other studies in orthopedic settings have demonstrated [ 20 – 22 ]. Moreover, we decided to collect PROMIS measures as our standard measure, as opposed to region-specific or legacy measures associated with each clinical division, which allowed us to scale the collection of PROMs across our department while minimizing the complexity of EHR programming for administering and reporting our PROMs.…”

Implementation of an Online Glaucoma-Specific Quality of Life Computerized Adaptive Test System in a US Glaucoma Hospital

“…Like other CAT implementation studies, 13 , 26 , 27 our GlauCAT tests took, on average, 1.5 to 3 minutes to complete, highlighting the effectiveness of CAT in delivering efficient, low-burden PROM measurement. Indeed, GlauCAT provided 6 important QOL outcomes in <10 minutes (median), which compares promisingly with many paper-pencil PROMs that provide only 1 to 2 outcomes in a similar amount of time.…”

“…Integration with EMR is a known barrier to PROM implementation due to interoperability and system infrastructure issues. 34 However, several studies 13 , 27 have managed to overcome these technical barriers through dedicated information technology and software programmer teams. Enabling patients to complete the GlauCAT tests at home via a secure automated link is planned, which is especially pertinent in the era of coronavirus disease 2019 (COVID-19), where patients are reluctant to attend the clinic or share tablets.…”

Leveraging Patient Reported Outcomes Measurement via the Electronic Health Record to Connect Patients with Cancer to Smoking Cessation Treatment

“…Third, to enable reach to diverse patients in terms of cancer and cancer treatment, the PRO system should be implemented in all departments of a cancer center. This will require comprehensive training within and across departments to ensure the active support of cancer care teams, which in turn may increase screener completion rates [ 50 ]. Finally, the outreach protocol triggered by a positive screen must be efficient and timely to ensure rapid connection to treatment.…”