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.