PS1-49: Methods for Integrating Patient-Reported Outcomes Into the Electronic Health Record

Abstract In this case report, the authors describe the implementation of a system for collecting patient-reported outcomes and integrating results in an electronic health record. The objective was to identify lessons learned in overcoming barriers to collecting and integrating patient-reported outcomes in an electronic health record. The authors analyzed qualitative data in 42 documents collected from system development meetings, written feedback from users, and clinical observations with practice staff, providers, and patients. Guided by the Unified Theory on the Adoption and Use of Information Technology, 5 emergent themes were identified. Two barriers emerged: (i) uncertain clinical benefit and (ii) time, work flow, and effort constraints. Three facilitators emerged: (iii) process automation, (iv) usable system interfaces, and (v) collecting patient-reported outcomes for the right patient at the right time. For electronic health record-integrated patient-reported outcomes to succeed as useful clinical tools, system designers must ensure the clinical relevance of the information being collected while minimizing provider, staff, and patient burden.

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Capturing a Patient-Reported Measure of Physical Function Through an Online Electronic Health Record Patient Portal in an Ambulatory Clinic: Implementation Study (Preprint)

10.2196/preprints.8687 ◽

2017 ◽

Author(s):

Jing Li ◽

Jinoos Yazdany ◽

Laura Trupin ◽

Zara Izadi ◽

Milena Gianfrancesco ◽

...

Keyword(s):

Electronic Health Record ◽

Physical Function ◽

Patient Reported Outcomes ◽

Health Record ◽

Patient Portal ◽

Rheumatology Clinic ◽

Patient Reported ◽

Physical Function Score ◽

Electronic Health ◽

White Patients

BACKGROUND Despite significant interest in the collection of patient-reported outcomes to make care more patient-centered, few studies have evaluated implementation efforts to collect patient-reported outcomes from diverse patient populations OBJECTIVE We assessed the collection of patient-reported outcomes from rheumatoid arthritis patients in an academic rheumatology clinic, using a paper and an online form through the electronic health record patient portal. METHODS We identified patients seen between 2012-2016 with ≥2 face-to-face encounters with a rheumatology provider and International Classification of Diseases codes for RA, ≥30 days apart. In 2013, our clinic implemented a paper version of the Patient Reported Outcome Measurement Information System (PROMIS) physical function form that was administered to patients upon their check-in at the clinic. In 2015, an online version of the form became available by way of the electronic health record patient portal to patients with active portal accounts. We compared the proportion of visits with documented PROMIS scores across age, race and ethnicity, and language and examined trends over time using a control chart. RESULTS We included 1078 patients with rheumatoid arthritis with 7049 in-person encounters at the rheumatology clinic over 4 years, with an average of 168 visits per month. Of the included patients, 80.4% of patients (867/1078) were female and the mean age was 58 (SD 16) years. The overall PROMIS physical function score documentation increased from 60.4% (1081/1791) of visits in 2013 to 74.4% (905/1217) of visits in 2016. Online score documentation increased from 10.0% (148/1473) in 2015 to 19.3% (235/1217) in 2016. African American patients were least likely to have a PROMIS physical function score recorded (55/88, 62.5% compared to 792/990, 80.0% for other racial or ethnic groups; P<.001). Compared with white patients, both African American and Hispanic patients were less likely to have active online electronic health record portal accounts (44/88, 50% and 90/157, 57.3% respectively, compared to 437/521, 83.9% of white patients; P<.001) and, once activated, less likely to use the online survey (6/44, 13.6% and 16/90, 17.8% respectively, compared to 135/437, 30.9% of white patients; P=.02). There was no significant difference in the proportion of any PROMIS physical function forms recorded between non-English vs English preferred patients. No significant differences were found across age or gender. CONCLUSIONS PROMIS physical function form completion improved overall from 2012-2016 but lagged among racial and ethnic minorities and non-English preferred patients. Future studies should address issues of portal access, enrollment, satisfaction, and persistence and focus on developing PRO implementation strategies that accommodate the needs and preferences of diverse populations.

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Implementation of Patient-Reported Outcomes in Routine Medical Care

American Society of Clinical Oncology Educational Book ◽

10.1200/edbk_200383 ◽

2018 ◽

pp. 122-134 ◽

Cited By ~ 48

Author(s):

Ethan Basch ◽

Lisa Barbera ◽

Carolyn L. Kerrigan ◽

Galina Velikova

Keyword(s):

Electronic Health Record ◽

Patient Reported Outcomes ◽

Clinical Care ◽

Self Report ◽

Routine Practice ◽

Health Record ◽

Patient Portals ◽

Free Standing ◽

Patient Reported ◽

Electronic Health

There is increasing interest to integrate collection of patient-reported outcomes (PROs) in routine practice to enhance clinical care. Multiple studies show that systematic monitoring of patients using PROs improves patient-clinician communication, clinician awareness of symptoms, symptom management, patient satisfaction, quality of life, and overall survival. The general approach includes a brief electronic survey, administered via the Web or an app or an automated telephone system, with alerts to clinicians for concerning or worsening issues. Patients have generally been asked to self-report on a regular basis (remotely between visits and/or at visits), with reminders prompting patients to self-report that are sent via email, text, or automated phone message. More recently, care management pathways for patients and clinicians have been triggered by PRO system alerts. PRO systems may be free-standing, integrated into electronic health record systems or patient portals, or native functionality of an electronic health record. Despite potential benefits, there are challenges with integrating PROs into practice for monitoring patient status, as there are with any modifications to existing clinical processes. These challenges range from administrative to technical to workflow. A session at the 2018 ASCO Annual Meeting was dedicated to the implementation of PROs in clinical practice. The session focused on practical examples of PRO implementations, with honest reflections on barriers and strategies that may be generalizable to other systems looking to implement PROs. Panelists for that session are the authors of this paper, which describes their respective experiences implementing PROs in practice settings.

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All together now: findings from a PCORI workshop to align patient-reported outcomes in the electronic health record

Journal of Comparative Effectiveness Research ◽

10.2217/cer-2016-0026 ◽

2016 ◽

Vol 5 (6) ◽

pp. 561-567 ◽

Cited By ~ 12

Author(s):

Roxanne E Jensen ◽

Claire F Snyder ◽

Ethan Basch ◽

Lori Frank ◽

Albert W Wu

Keyword(s):

Electronic Health Record ◽

Patient Reported Outcomes ◽

Health Record ◽

Patient Reported ◽

Electronic Health

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The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health

Clinical Trials ◽

10.1177/1740774520928399 ◽

2020 ◽

Vol 17 (4) ◽

pp. 351-359

Author(s):

Steven B Zeliadt ◽

Scott Coggeshall ◽

Eva Thomas ◽

Hannah Gelman ◽

Stephanie L Taylor

Keyword(s):

Electronic Health Record ◽

Real Time ◽

Patient Reported Outcomes ◽

Health Record ◽

Business Practices ◽

Electronic Health Record Data ◽

Integrative Health ◽

Patient Reported ◽

Record Data ◽

Electronic Health

Electronic health record data can be used in multiple ways to facilitate real-world pragmatic studies. Electronic health record data can provide detailed information about utilization of treatment options to help identify appropriate comparison groups, access historical clinical characteristics of participants, and facilitate measuring longitudinal outcomes for the treatments being studied. An additional novel use of electronic health record data is to assess and understand referral pathways and other business practices that encourage or discourage patients from using different types of care. We describe an ongoing study utilizing access to real-time electronic health record data about changing patterns of complementary and integrative health services to demonstrate how electronic health record data can provide the foundation for a pragmatic study when randomization is not feasible. Conducting explanatory trials of the value of emerging therapies within a healthcare system poses ethical and pragmatic challenges, such as withholding access to specific services that are becoming widely available to patients. We describe how prospective examination of real-time electronic health record data can be used to construct and understand business practices as potential surrogates for direct randomization through an instrumental variables analytic approach. In this context, an example of a business practice is the internal hiring of acupuncturists who also provide yoga or Tai Chi classes and can offer these classes without additional cost compared to community acupuncturists. Here, the business practice of hiring internal acupuncturists is likely to encourage much higher rates of combined complementary and integrative health use compared to community referrals. We highlight the tradeoff in efficiency of this pragmatic approach and describe use of simulations to estimate the potential sample sizes needed for a variety of instrument strengths. While real-time monitoring of business practices from electronic health records provides insights into the validity of key independence assumptions associated with the instrumental variable approaches, we note that there may be some residual confounding by indication or selection bias and describe how alternative sources of electronic health record data can be used to assess the robustness of instrumental variable assumptions to address these challenges. Finally, we also highlight that while some clinical outcomes can be obtained directly from the electronic health record, such as longitudinal opioid utilization and pain intensity levels for the study of the value of complementary and integrative health, it is often critical to supplement clinical electronic health record–based measures with patient-reported outcomes. The experience of this example in evaluating complementary and integrative health demonstrates the use of electronic health record data in several novel ways that may be of use for designing future pragmatic trials.

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eSyM: An Electronic Health Record–Integrated Patient-Reported Outcomes–Based Cancer Symptom Management Program Used by Six Diverse Health Systems

JCO Clinical Cancer Informatics ◽

10.1200/cci.21.00137 ◽

2022 ◽

Author(s):

Michael J. Hassett ◽

Christine Cronin ◽

Terrence C. Tsou ◽

Jason Wedge ◽

Jessica Bian ◽

...

Keyword(s):

Health Care ◽

Electronic Health Record ◽

Symptom Management ◽

Patient Reported Outcomes ◽

Health Care Systems ◽

Management Program ◽

Health Record ◽

Patient Reported ◽

Care Systems ◽

Electronic Health

PURPOSE Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available. METHODS As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes. RESULTS eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts. CONCLUSION eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

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Incorporating the patient’s voice into electronic health records through patient-reported outcomes as the “review of systems”

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocu007 ◽

2015 ◽

Vol 22 (4) ◽

pp. 914-916 ◽

Cited By ~ 18

Author(s):

Arlene E Chung ◽

Ethan M Basch

Keyword(s):

Electronic Health Record ◽

Patient Reported Outcomes ◽

Clinic Visit ◽

Health Record ◽

Symptom Experience ◽

Full Spectrum ◽

Clinical Encounters ◽

Patient Reported ◽

Electronic Health ◽

Competing Priorities

Abstract Owing to lack of standardization for eliciting patient symptoms, the limited time available during clinical encounters, and the often-competing priorities of patients and providers, providers may not appreciate the full spectrum of the patient’s symptom experience. Using electronically collected patient-reported outcomes to capture the review of system outside of the clinic visit may not only improve the efficiency, completeness, and accuracy of data collection for the review of system, but also provide the opportunity to operationalize incorporating the patient’s voice into the electronic health record. While the necessary technology is already available, multiple stakeholders, including electronic health record vendors, clinicians, researchers, and professional societies, need to align their interests before this can become a widespread reality.

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What does social isolation have to do with my arthritis? Patient and provider views of the implementation of an electronic Social Determinants of Health risk assessment tool

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/1071181320641164 ◽

2020 ◽

Vol 64 (1) ◽

pp. 707-710

Keyword(s):

Electronic Health Record ◽

Social Determinants Of Health ◽

Social Determinants ◽

Assessment Tool ◽

Determinants Of Health ◽

Health Record ◽

Institute Of Medicine ◽

Patient Reported ◽

Item Responses ◽

Electronic Health

Social Determinants of Health (SDoH) are the conditions in which people are born, live, learn, work, and play that can affect health, functioning, and quality-of-life outcomes. The Institute of Medicine charged healthcare institutions with capturing and measuring patient SDoH risk factors through the electronic health record. Following the implementation of a social determinants of health electronic module across a major health institution, the response to institutional implementation was evaluated. To assess the response, a multidisciplinary team interviewed patients and providers, mapped the workflow, and performed simulated tests to trace the flow of SDoH data from survey item responses to visualization in EHR output for clinicians. Major results of this investigation were: 1) the lack of patient consensus about value of collecting SDOH data, and 2) the disjointed view of patient reported SDoH risks across patients, providers, and the electronic health record due to the way data was collected and visualized.

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