Patient-driven data can be used to improve care from both the patients’ and providers’ perspective, according to the speakers presenting at ABMS’ recent portfolio-based assessment webinar entitled Exploring the Role of Patient-reported Outcomes and Patient Experience of Care within Portfolio-based Assessments.
Judy Baumhauer, MD, MPH, Professor and Associate Chair of Academic Affairs for the Department of Orthopaedic Surgery at the University of Rochester Medical Center (URMC), discussed why patient-reported outcomes (PROs) are important, how to collect them, and how to use them to advance patient care. Joining Dr. Baumhauer, Thomas Lee, MD, Chief Medical Officer for Press Ganey Associates, demonstrated how patient experience-of-care metrics can be used to improve the delivery of high-value care.
Less than two percent (32) of the 1,958 quality indicators in the National Quality Measures Clearinghouse are PROs, which Dr. Baumhauer defined as a health outcome directly reported by the patient who experienced it. The problem is that there is a disconnect between what patients and providers think are important, she said. Citing top goals and concerns about breast cancer decisions, only seven percent of patients said it was keeping their breast compared with 71 percent of providers; only 33 percent of patients indicated looking natural without clothes compared with 80 percent of providers. “This illustrates why PROs are so pivotal to the care we provide to our patients,” Dr. Baumhauer noted.
Providers who want to know how their patients are doing just need to ask, she said. When patients come to the University of Rochester Medical Center (URMC), they are asked to complete one or more health assessment on an iPad as part of the check-in process. Their scores are incorporated into a PRO platform developed by the institution called UR Voice, which stands for Validated Outcomes in Clinical Experience. Then they are electronically linked to the electronic health record, enabling the patient and provider to view them together during the appointment. The assessments are based on the Patient-Reported Outcomes Measurement Information System, known as PROMIS®, a set of person-centered symptom based measures that evaluates and monitors physical, mental, and social health in adults and children. “We use the PROMIS model because it incorporates biopsychosocial assessments,” Dr. Baumhauer explained. These assessments can be customized based on the needs of the patient and provider and take approximately one minute per symptom domain to complete.
Collecting data for the past three years, URMC has gathered more than two million scores on UR Voice, to date. Within the Orthopaedic Surgery department, data on more than 230,000 unique patients have been captured. Comparing the scores of individual patients to the U.S. mean population through the use of t-scores, providers and patients can use the data to help guide clinical decisions, she said. The data can be evaluated to see if the patient is making progress on his/her current treatment regimen and help determine next steps in the treatment plan. For example, if a patient is contemplating knee replacement surgery, the patient’s PROMIS data can be compared with similar patients who already had knee replacement surgery to determine whether this patient would benefit with pain relief or improved physical function after a knee replacement surgery, Dr. Baumhauer said. If the PROs do not suggest a positive improvement, the patient may want to explore other non-operative treatment options and be reassessed at a later timepoint, such as in one year.
The department is exploring the use of PRO data to determine patients at risk for falls. As a result, the department now offers a Falls Prevention Program designed to improve balance and strength for at-risk patients. Using PROMIS to influence upstream screening to identify patients at risk for falling and employing preventative programs to improve balance and physical function, and decrease falls is exactly what clinicians should be doing to help their patients, she added.
Benefits of collecting PROs include advancing patient care while engaging and educating patients as well as sharing decision making with them, Dr. Baumhauer stated. They can be used to assess treatment responses for individuals, groups, and patient populations; develop preventative health strategies; maximize healthy behavior; and appropriately allocate health care resources. She noted that the American Board of Orthopaedic Surgery collects PROs (the PROMIS model) to assist in its Board Certification and continuing certification processes.
While Dr. Baumhauer demonstrated how PROs can be used to improve the care of individual patients, Dr. Lee shifted the discussion to how patient data can be used to improve the care of clinical teams. “It’s important that we get over the notion that these data points are being used to judge us,” he stated. “Instead, we should be looking at the data as information that can help us get better at what we do.”
To determine what patients really value, Press Ganey looked at 937,000 responses to its patient experience of care surveys. The No. 1 reason patients are likely to recommend a doctor or practice is, by far, confidence in the provider, Dr. Lee said. Next is coordination of care, followed by empathy and communication. “You don’t see wait times,” he added.
Linking patient experience and clinical quality, it turns out that hospitals that performed poorly across five patient-ranked domains (i.e., cleanliness, nursing, physician care, overall, likelihood to recommend) also performed worse than top performers in four areas of clinical quality (i.e., hospital-acquired conditions, lengths of stay, readmission rate, and safety performance). “These data show that patient experience is not in conflict with other kinds of issues you think of as quality care and business performance,” Dr. Lee said.
Physician engagement is clearly associated with patient experience, he said, noting that facilities in the top quartile for patient experience measures also rank 30 to 40 points higher on physician engagement compared with those in the bottom quartile for patient experience. Basically, physicians liked working at the facilities where patients thought the care was better, Dr. Lee said. Press Ganey is the largest administrator for Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, in the country.
“The good news is that the major factors driving the likelihood to recommend [a health care organization] are within our control,” he said. Moreover, they are the same across all settings. “What drives patients’ peace of mind is having good clinicians who work well together, show that they care, and make an effort to communicate with the patients. I haven’t met any physicians yet who don’t think these drivers are completely consistent with professional values,” Dr. Lee concluded.
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