PROMising Steps in Care Redesign

Neil Wagle, MD, MBA

It's PROM time at BWH-not the kind of prom a high school student anticipates, but a new step forward in efforts across Partners to redesign care. The collection of PROMs, or patient-reported outcomes measures, is underway at several BWH practices as a way to improve patient care.

"We track adverse events, readmissions and mortality," said Neil Wagle, MD, MBA, the Partners HealthCare medical director for PROMs. "But we don't do a good job of tracking all the outcomes that matter to our patients."

Such meaningful outcomes might include whether a patient can climb stairs without feeling pain, lie down without becoming short of breath or feel well enough to go out and socialize. "When we measure these things, we can start to figure out how we can improve our patients' quality of life," Wagle said.

Health care leaders have been discussing such measures for decades, but the logistical challenge of collecting and sharing this kind of information has always prevented it. To make the information meaningful, it must be made available to multiple care providers who can intervene in a patient's health and, on a broader scale, use it to build population data.

The PROMs initiative is rolling out across Partners, with several practices at BWH and MGH in the pilot stages for diabetes patients and patients undergoing coronary artery bypass graft (CABG) surgery. According to Wagle, no other organization has collected PROMs on such a large scale or systematic way as Partners aims to through the care redesign initiative.

Ultimately, the program aims to achieve the following through data collection and sharing:

• For individual care providers to improve the health of individual patients
• For population data to improve patient engagement and facilitate better medical decision making.
• For researchers and population managers to find answers to general health questions

"This is an exciting time for primary care to develop new methods and models to improve care and patient outcomes," said Asaf Bitton, MD, assistant medical director of Brigham and Women's Advanced Primary Care Associates at South Huntington, one of the practices piloting PROMs. "We're optimistic that this could provide a novel platform to tell us how people are functioning so we have an opportunity to intervene and improve care that matters most to them."

A new international collaborative will begin in Boston, centered around the Partners PROMs project, said Wagle. The collaborative will focus on getting other institutions around the world to collect patient reported outcomes measures and measure them in the same way, so there is meaningful data to compare across institutions.

How it Works
A medical assistant hands the patient an iPad in the waiting room. The patient receives a short explanation of the PROM project and then answers 15 questions about how he or she feels, ranging from their pain level to a question about their social relationships-if they feel well enough to socialize with friends and family, for example.

The process concludes with a question about how the patient would like to receive follow-up communication, whether by e-mail or phone. Every six months, the patient receives a follow-up questionnaire. (The interval varies depending on the condition; diabetes patients receive follow up every six months, but CABG patients receive it every three.)

"This status report is a good tool for care providers to have," Wagle said.

PROMs may work especially well in a medical home model, where providers can quickly assess a patient's decline in mental health, for example, and connect the patient with a social worker or behavioral health specialist immediately.

"It's very patient-centered," said Sonia Freitas, PharmD, project lead for PROMs at South Huntington, which focuses on diabetes patients. "Patients may have their diabetes under control but may not be feeling healthy or well overall. PROMs can help clinicians to address the issues that are most important to patients-those that may be preventing patients from meeting their goals."

In November, the first of the PROMs reports will be available for care providers on LMR. In addition to South Huntington, diabetes patients at Brigham Circle Medical Associates and Brigham and Women's Primary Care Associates at Newton Corner are also part of the pilot. The BWH Watkins Clinic and the MGH Cox Clinic are piloting PROMs for CABG patients.

"Collecting this information opens up a new domain of measuring patients' experience of care with us," said Bitton. "It will help us be more responsive to their needs, and it will help our providers to consider how our treatments are impacting patients' lives-or not."

PROMs on the Horizon
Next year, the program will expand to multiple other conditions, possibly including total knee replacement patients. "Patients have knee replacement surgery because they have pain and can't walk," Wagle said. "But we don't systematically track these symptoms when they leave, so we don't measurably know if they walk better or have less pain."

It will also expand to three more practices across Partners for diabetes patients, as well as CABG patients, and later include stroke patients and urology patients, among others, across several Partners hospitals.  

This type of data is not only useful to care providers, but also to patients considering certain procedures, such as a total knee replacement. The ability to look at data from others who have had the surgery may better inform their own decisions.