Using PROMs to Improve Quality: Clinical Management of Individuals
Eugene C. Nelson, DSc, MPH
Director Population Health & Measurement
Dartmouth- Hitchcock Professor, Community and Family
Medicine The Dartmouth Institute
Acknowledgements: J. Weinstein, R. Reid, S. Lindblad, J. Wasson, C. Kerrigan, W. Gozansky, A. Wu, P. Batalden and financial support from The Dartmouth Institute, The Dartmouth Center for Healthcare Delivery Science, the Robert Wood Johnson Foundation, PCORI and NIH-NIA.
Wayne Gretzky
An old story … great clinical outcomes & better function
(because of PROMs)
2
Insert JAMA article
Jack Kirk, MD Founder
Dartmouth COOP Project
JAMA 1983
Topics
• Using PROMS for clinical management of individuals to improve quality – Where? – How? – Why? – Research questions?
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1. Where are PROMs Being Used for Individual Patients to Improve Quality?
• 18 Dartmouth Programs Using PROMs for Individuals
– Orthopedics: hip & knee & shoulders & spine
– Plastics: hand & breast – Pain clinic: chronic pain – Hematology/Oncology: breast, head &
neck, neuro-oncology, prostate – Psychiatry: sleep disorders,
depression, anxiety – OB-GYN: uro-gynecology, post
partum depression – Rehabilitation: functional restoration – Surgery: Pre-admission testing – Vascular: vascular conditions – Primary care: assessment & plans
• Registries: Sweden & International
– Sweden: Rheumatology (64), CF (6), HIV (8) & rest starting
– ImproveCareNow: pediatric IBD improvement network
– Parkinson’s Disease International Qii registry
• Progressive Systems – High Value Healthcare Collaborative
(100 m patients & 20 systems) – HowsYourHealth: British Columbia
& US primary care practices – UPMC, UCLA, Duke, Michigan,
Cleveland Clinic, Cincinnati Childrens, Geisinger, etc.
Not yet mainstream but a very partial listing
2. How are PROMs Being Used for Individual Patients to Improve Quality?
• Primary care – Dartmouth COOP (New England) – HowsYourHealth (British Columbia) – Kaiser-Permanente (Colorado) – Group Health Cooperative (Washington state)
• Specialty care – Dartmouth Spine Center – Swedish Rheumatology Quality Registry
5 Some Cases
Primary Care Cases
HowsYourHealth: British Columbia
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Sponsored by British Columbia Medical Association & Provincial Government • Free for use by any person or patient • Health assessment • Personal health care plan • Outcomes tracking • Health & decision making information • Feed forward PROMs pre-visit • Used for co-production of care & self
management • Creates a patient registry for practices • Also endorsed by AAFP, ACP, AHRQ http://www.howsyourhealthbc.ca/
Coming Next: HealthConfidence Massachusetts
John Wasson, MD
Kaiser-Permanente Colorado
Kaiser-Permanente Colorado •Annual wellness visits for primary care patients age 65 plus •PROMs based health assessment to make patient’s personal care plan •Goal is 100% participation •Last year reached 45,000 out of 80,000 patients
PROMs Drives Plan
Wendee Gozansky
Group Health Coop: Primary Care
• Started in 2006 by Rob Reid & colleagues
• Strategy: redesign a failing primary care system
• Tactic: use patient-reported data to improve preventive & chronic care
• Integrated with Epic electronic medical record
• >70% primary care patients using feed forward data with their primary care teams
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Patient Home Page PHR
Example of the eHRA Questions
Patient Report Delivered by Web Portal
Chronic care tracking
Risk status tracking
Next actions
Report Delivered to the Clinical Team
Call to action
EHR
Specialty Care Cases
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Using PROMs with Individuals: Dartmouth Spine Center
© 2000, Trustees of Dartmouth College, Batalden, Nelson, Wasson
Referral or Visit Request
Orientation &
PROMs
Initial Work Up
P lan of Care
Functional Restoration
Chronic Care Management
Acute Care
Management
Disease Status
Expectations For Good Care
Sunk Costs
Functional & Risk Status
Disease Status
Experience Against
Need
Incremental Costs
Functional & Risk Status
Palliative Care
People w ith healthcare needs
People w ith healthcare needs met
Feed Forward
Feedback Improvement registry Public reports website SPORT & research
Patient Perception History & Symptoms
Red Flags
The summary report generated from patient-reported data is critical to a physician's ability to care for a patient: same page care Functional
Status
Risk Factors
Disease Status
Nov 26 2006
May 31 2007 SPORT NIH Trial • 13 Centers • 3 spine conditions • Feed forward PROMs • Prospective controlled trial • 6 years of follow up
1.64
QALY 1.44 QALY
Functional
Clin
ical
Costs
Satisfaction
Reduced Oswestry
Symptoms Satisfied With Improvement
Total Direct & Indirect Costs
Physical SF-36 Improvement Herniated Disk
Outcomes @ 2 Years Non-Surgery Surgery
44 Ave Age 43% Female
30 Ave Age 45% Female
Cost Per Quality Adjusted Life Year Added
By Surgery $34,355
$74,870
44
30
59%
78%
-25
-37
$13,108
$27,341
$34,355
Moving research results back to patient care …
risk calculator used at point of care for Shared Decision
Making
Sweden: Rheumatology Quality Registry (SRQ)
• SRQ uses PROMs feed forward data in flow of care: better care for individuals, practice improvement, new care models, retrospective & prospective research
• Started in 1995 & covers > 90% of Swedish patients with RA in 64 centers
• Innovation: fundamental change in way care is being delivered … active co-design of care by patient, nurse and doctor
• Swedish government & Michael Porter … a model for all of Sweden
• RWJF … considering as a model for US registries
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Staffan Lindblad
Patient Registering Data on Swollen and Tender Joints on a Touch Screen
Computer In The Waiting Area.
Summary Overview of a Rheumatology
Patient
Case in point: Swedish National
RA Registry … This patient is doing better …
N of 1 experiment… Responded to biologics
January - March
June - December
Key point: Swedish health system is doing better: All Patients in the SRQ, from 1994 – 2006*
*Black line shows DAS at initial visit and blue after 6 months and turquoise after 12 months.
Patients sicker at 1st visit
Patients better at 6 & 12 months
3. Why ???
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My Health Status
My Healthcare Decisions
My Healthcare
Plan
My Health
Outcomes
PROMs & Patient Generated Data = Guidance System for Getting It Right … •Health care decisions right for Amy •Health care plans right for Amy •Health care outcomes best for Amy •Thus, Amy is able to co-produce her care
Why use PROMs in flow of care for clinical management of individuals? Amy
Why use PROMs for clinical management?
• Using PROMs in flow of care using feed forward principles is a triple play 1. Better care for individual patients
• Tracking outcomes over time • Agency for co-production of care
2. Better data for practice improvement • Comparative benchmarking vs other
practices • Measurable improvements
3. Better data base for research • Participation in research
“collaboratory” • Retrospective & prospective
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3rd 2nd
1st
4. Research Questions • How to optimize use of PROMs for
– For patients? • So they get what they need as co-producers of care
– For front line practitioners? • So it is easier to serve patients according to needs &
preferences – For HIT developers?
• So data is fed forward, integrated and easy to use by patients and clinicians
– For health systems and commissioning boards to promote transparency, improvement & accountability
26 How to be fit for an “e” future ??
Aim: Patient-centered decision support for co-production of good care, better health & more confidence in self-management.
Key Mechanism: Integrating patient’s voice into flow of care & EHR to co-produce care plans that reflect needs & values.
Feed Forward Clinical Data
Key Patient Outcomes
Experience
Disease Function
Risks Costs
Confidence
Patient & Family System
Provider & Care Team System
The Clinical Microsystem
Co-Production
How to Make PROMs for Individuals Fit for the Future?
Feed Forward PROMs Data
Patient Value Network Features
• Curated & facilitated** • Patients with shared problem** • Subject matter expertise** • Peer support** • Information I need for self-care** • My personal health plan • E.g., PatientsLikeMe, HowsYourHealth
Patient facilitated Networks
Patients Pull
Clinical Registry Features
• Feed forward PGHD at point of care for care planning & outcomes tracking**
• Comparative data for practice improvement**
• Research Database as by-product** • Maintenance of Certification • PQRS (Physician Quality Reporting
System) data feeds • Data Flows Designed into Work Flows • E.G. SRQ, NPF Registries
Providers Pull
Clinical Registries
© Copyright 2013: E.C. Nelson, P. Batalden, S. Lindblad
PHR EHR
Selected References
1. Black N. Patient reported outcome measures could help transform healthcare. BMJ 2013, Jan 28; 346:f167. 2. Boyce MB, Brown JP. Does providing feedback on patient-reported outcomes to healthcare professionals result in
better outcomes for patients? A systematic review. Qual Life Res 2013, Mar 17. 3. Essen A, Lindblad S. Innovation as emergence in healthcare: unpacking change. Soc Sci & Med 2013, (93): 203-211. 4. Wu AW. Advances in the Use of Patient Reported Outcome Measures in Electronic Health Records Including Case
Studies. Nov 7, 2013. PCORI National Workshop to Advance the Use of PRO Measures in Electronic Health Records. Atlnata, GA.
5. Meyer GS, Nelson EC, Pryor DB, James B, Swensen SJ, Kaplan GS, Weissberg JI, Bisognano M, Hunt GC, Yates GR, Hunt GC: More quality measures versus measuring what matters: a call for balance and parsimony. BMJ Quality and Safety Journal August 2012. Published Online First: 14 August 2012 doi: 10.1136/bmjqs-2012-001081
6. Snyder C, Aaronson NK, Choucair AK, et al. Implementing patient-reported outcomes assessment in clinical practice: a review of options and considerations. Qual Life Res2012 Oct;21(8):1305-14.
7. Nelson EC, Butterly J, Colacchio TA, Mastanduno MP, Foster TC, Batalden PB. Better Patient and Population Outcomes: Practical Approaches that Health Care Systems Can Adopt for Measuring the Health of Patients and Populations, in Sustainably Improving Health Care: Creatively Linking Care Outcomes, System Performance and Professional Development Batalden PB, Foster TC (eds.), Radcliffe Publishing, Ashland, Ohio, 11-31, 2012.
8. Nelson EC, Hvitfeldt HF, Reid R, Grossman D, Lindblad S, Mastanduno MP, Weiss LT, Fisher ES, Weinstein JN. Using Patient-Reported Information to Improve Health Outcomes and Health Care Value: Case Studies from Dartmouth, Karolinska and Group Health. Technical Report. The Dartmouth Institute for Health Policy and Clinical Practice. 2012
9. Wasson JH, Forsberg HH, Lindblad S, Mazowita G, McQuillen K, Nelson EC. The Medium Is the (Health) Measure - Patient Engagement Using Personal Technologies. Journal of Ambulatory Care Management. 35 (2); 109-117April-June 2012, doi: 10.1097/JAC.0b013e31823a235e
10. Nelson EC, Fisher ES, Weinstein JN: A Perspective on Patient-Centric, Feed-Forward “Collaboratories”in IOM (Institute of Medicine) Engineering a learning healthcare system: A look at the future: Workshop summary, The National Academies Press, Washington, DC, 149-170, 2011.
11. Nelson EC, Batalden PB, Godfrey MG, Lazar JS: Value by Design: Developing Clinical Microsystems to Achieve Organizational Excellence, Jossey-Bass, 2011.
12. Hvitfeldt H, Carli C, Nelson EC, Mortenson DM, Ruppert BA, Lindblad S. Feed Forward Systems for Patient Participation and Provider Support; Adoption Results from the Original US Context to Sweden and Beyond. Quality and Safety in Health Care, 18(4); 247-256, October-December 2010.
13. Christensen CM, Grossman GH, Hwang J. The innovators prescription: a disruptive solution for health care, McGraw-Hill, 2008.
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