Implementing Point-of-Care Patient Reported Outcomes (PROs):  Did Someone Say This Would Be Easy?

SAFTINet ConvocationMay 19th, 2011

Overview• PRO definition and background• Impact on workflow: In a busy, resource-

drained environment• Electronic data capture: Within the EMR? 

Outside of the EMR?• Data coding: Making sense of the data • Use of the data: Real-time data capture

with incorporation into decision tools

Overview• PRO definition and background• Impact on workflow: In a busy, resource-

drained environment• Electronic data capture: Within the EMR? 

Outside of the EMR?• Data coding: Making sense of the data • Use of the data: Real-time data capture

with incorporation into decision tools

PRO Definition• A patient-reported outcome or PRO is a

questionnaire used in a clinical trial or a clinical setting, where the responses are collected directly from the patient.

• Example in SAFTINet: Asthma Control Test (ACT, C-ACT)

Background: Process of Selecting ACT• Assessed SAFTINet Partner Requirements for a PRO

tool– Simplicity– Does not interfere with workflow– Appropriate for literacy level and language of patient

populations– Alignment with other organizational efforts and

initiatives• Assessed SAFTINet PRO experience

– Diverse– 1 partner already uses an asthma PRO (ACT)

Background: Why use a PRO for asthma?• Clinical utility

– Screening tool– Patient monitoring tool– Patient centered care (feedback to patients)– Decision aid– Facilitating multidisplinary team communications

• Research utility– Standardized evaluation of outcomes

• Why asthma?– Effects of disease on functioning and quality of life not accounted for in

standard EHR data– Severity of disease difficult to assess– Patients experience symptoms (unlike hypertension or high cholesterol)

Background: ACT Format Examples

Background: ACT Proposed Timeline - 2011

Explore options for asthma

PROs

Discuss PRO with provider

groups

Select asthma PRO tool

Make implementation plan for asthma

PRO tool

Create infrastructure for PRO tool deployment (e.g., EHR

template, iPad purchase &

configuration)

PRO tool training

Begin using asthma PRO

tool

March

April May June July Sept Oct

Background: Process for making implementation plan for asthma PRO• PEC-led structured interviews with

partners• Topics covered in interviews are in

following slides

Resources• Manpower• Information systems and technical support• Space• Financial investment (SAFTINet funds

available)

Selecting patients to complete the tool• Ambulatory patients with asthma

– How would they be identified?• How often would they complete the tool?

– Every ambulatory visit?• When does the patient complete the tool?

– Beginning of visit?

Mode of administration• Person completing the tool

• Self-administration• Interviewer administration

• Medium for presentation of tool and data collection• Pencil and paper survey• EHR template• Portable devices (e.g., iPad)• Web-based• Telephony-based

Scoring• Who will score the results?

• Patient• Member of the health care team

• What tools are available to assist with scoring?

Presentation of results• Are results presented to patient/provider?• If yes:

• When are results presented?• At time of visit?

• Where are results presented?• Part of workflow?

• How are results presented?• Numeric or graphical presentation

Data entry• How will data be entered?• Depends on mode of administration

Interpreting and responding to scores

• Algorithms (Asthma APGAR)• Meaningful scores (ACT)• Linking to clinical guidelines

Evaluation• Plans for evaluating use of tool on:

• Process/workflow• Quality of care

Barriers• Clinicians

– Lack of familiarity with the instruments– Doubt about the ability of pros to modify outcomes– Time and resource constraints– Disagreements over impact on patient-clinician relationship

• Patients – Literacy– Being too sick to complete questionnaires– Concern about impact on relationship with clinician

• Health system – Reimbursement– Fit within the clinical workflow

Anticipated barriers• Generate list of perceived barriers and

potential solutions

Process for selecting a tool and an implementation strategy• Provider meetings?• IT conversations?• Decision making?• Trainings?

Overview• PRO definition and background• Impact on workflow: In a busy, resource-

drained environment• Electronic data capture: Within the EMR? 

Outside of the EMR?• Data coding: Making sense of the data • Use of the data: Real-time data capture

with incorporation into decision tools