realizing the promise of patient-reported outcomes measures

Realizing the Promise of Patient-Reported Outcome Measures

Our Experience at Partners HealthCare

Rachel Clark Sisodia, MDPartners HealthCare, Boston MassachusettsMedical Director for PROMs, Massachusetts General HospitalAsst. Professor of Obstetrics, Gynecology and Reproductive BiologyDecember 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

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

What aren’t we measuring?

Center for Population Health | Quality, Safety, and Value 9

Outcomes in Prostate Cancer

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.Ex

aleOne Year

• 0-2: None.

• 3-4: Mild.

• 5-6: Moderate.

• 7-12: Severe.Ex

Three Years

Sexual Dysfunction After Radical Prostatectomy

• 0-2: None.

• 3-4: Mild.

• 5-6: Moderate.

• 7-12: Severe.Ex

eOne Year

• 0-2: None.

• 3-4: Mild.

• 5-6: Moderate.

• 7-12: Severe.Ex

Three Years

Outcomes in Multiple Dimensions

Confidential and Peer-Review Protected.Do Not Distribute

Bowel Symptoms

IncontinenceVitality

“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

PROMs in Patient Care

Better Shared Decision Making

Happier Providers, More Personalized Care

• 0-2: None.

• 3-4: Mild.

• 5-6: Moderate.

• 7-12: Severe.Ex

aleOne Year

• 0-2: None.

• 3-4: Mild.

• 5-6: Moderate.

• 7-12: Severe.Ex

eOne Year

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

Outcomes After Laminectomy: Leg Pain

Effect on Providers

Perhaps paradoxically, when embraced, this additional datasaves 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

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 time of surgery.

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

Implementation

Technical and Operational Solutions

Steps to Implement a PROMs Program

Leadership buy-In (use other

systems’ examples to sell it).

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 existOrthopedics, 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.

Ongoing Challenges

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

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.

Questions & Answers

realizing the promise of patient-reported outcomes measures

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