CME OnDemand: Using Patient Reported Outcomes in the Office to Impact Efficiency, Selection, and Patient Satisfaction-Foot & Ankle Focus: Using Patient Reported Outcomes in the Office to Impact Efficiency, Selection, and Patient Satisfaction

Foot & Ankle Focus: Using Patient Reported Outcomes in the Office to Impact Efficiency, Selection, and Patient Satisfaction

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On behalf of AOFAS, I want to welcome you to tonight's program, Using Patient-Reported Outcomes in the Office to Impact Efficiency, Selection, and Patient Satisfaction.  It will be moderated by Dr. Judy Baumhauer. Joining her are Drs. Amanda Holloran, David Truffaut, and David Bernstein.  You can find their full biographies and disclosures in the program document posted in the chat box and in the AOFAS On-Demand Education Center.  2023 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported by a  major grant from Stryker, and additional funding from Anthrax. To support education programs like this, make a donation to the foundation on our website  or by texting GIVEAOFAS to 41444. I'd like to run through a few housekeeping items before we kick off the presentation.  For technical difficulties, please try closing your browser and logging back in the same way you did the first time.  Registered attendees may earn one hour of AMA, PRA, Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to Claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast.  The webinar is being recorded and will be available for on-demand viewing on the On-Demand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab on your navigation bar.  If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit our website to register for upcoming events, including our next Foot  and Ankle Focus webinar on Tuesday, August 15th, and the AOFAS Annual Meeting in Louisville, Kentucky. I will now turn the program over to Dr. Baumhauer to begin. Thank you.  Thanks so much, Lucas. It's really a delight. We're all delighted to present to you a little bit about patient-reported outcomes and how they can be useful in the clinic.  This is really a case-use presentation to talk to you about how things can occur in the clinic space to make your work more efficient.  So we'll just share our screen here in just a minute and get going.  All right, everyone see that okay? Yeah, I see little boxes in the middle. Is there supposed to be little boxes in the middle? There, that's gone now. Perfect.  So it's using patient-reported outcomes in the office to impact efficiency, selection, and patient satisfaction.  And I'm really delighted to be joined by my couple of partners, Amanda Hollerin and Dave  Chufo, as you heard before, and Dave Bernstein, who was with us for years as a medical student and is now finishing up his residency at Harvard and has been an expert.  He actually has taken a year off this year to talk a little bit about patient-reported outcomes and really health care policy surrounding that. Next slide.  So our next slide shows... Oh, sorry. That's okay. There we go. So the next slide showed our disclosures, which were already disclosed at the very beginning.  I'd like to start these talks off by giving you the definition of a patient-reported outcome. People always ask me, they say, why is it different than some other things?  What makes a patient-reported outcome a patient-reported outcome? Now we know that about a month ago, you had a really great patient-reported outcome talk as well.  So we're not going to go into the details about patient-reported outcomes and the psychometrics and all of that stuff. We're really going to show you how we use it.  But I wanted to give you this definition. A patient-reported outcome is a health outcome that's directly reported by the patient who  experiences it, not the doctor, not the nurse, not the technician, the patient. So it isn't something like you get the history, the patient tells you, you know, I slipped  and I fell, I rolled my ankle over the edge of a sidewalk. And then you go back to your documentation and you say the patient rolled their ankle.  It actually comes in their language. So patient-reported outcome is really literally something the patient answers and then it goes directly into the electronic record. Next slide.  This shows you how we use it. This is a screenshot of Epic in our office. I just clicked on the outcomes tab above that. You can follow my little arrow going around.  The promise depression score is in red, the pain is in green, and the physical function, I'm sorry, is in red.  And we can hover over it and get the specific T-scores for each of those. On the X-axis is date, on the Y-axis is T-score.  We have a dashboard tab where we can see each of the patient-reported outcomes that the patient has completed and be able to drill down more into those.  We can also click on the details tab and understand what is asked and answered for each time, for each date that the patient has answered questions.  And we're going to show you how we use this. Next slide. I'm going to turn it over to, is it Amanda or Dave? I've forgotten now. I'll start out. Okay, Dave.  We're going to turn it over to Dave and he's going to be walking us through this. So I'm going to give you guys just a little background on PROMIS itself.  I know you guys heard a lot about lots of different patient-reported outcomes and there's hundreds and hundreds out there.  The one we use most is PROMIS, which stands for the patient-reported outcome measurement information system. So PROMIS is a little quicker and shorter.  It is an NIH-supported program. It has all validated questions and domains, which is nice that each of these questions  has been shown to be actually quite useful when they validate these against prior legacy outcomes and things like that. It is a computer-adaptive test.  So that means that each question is based a little bit on the patient's answers before that. So it saves time and redundancy.  If you can't run a mile, it's not going to ask you if you can run 10 miles, things like  that. So it does make it a little bit quicker, but it does require you to have a computer or an iPad or something like that.  So the scores that you're going to hear us talk about are T-scores, just like in statistics, that is kind of a standardized score that gives you that patient's data in relation  to the population average. And this is kind of an age and sex-matched average, so it's not just all comers. It's actually really related to that patient in specific.  So on our scale, or on the PROMIS scale rather, 10 points is one standard deviation. So population mean is 50.  So it's pretty intuitive that a patient's score in 60 is a standard deviation above average or 40 is a standard deviation below.  And that really lets patients and you benchmark people's outcomes against other people that are very similar to them, which is also nice for them to really understand their function  rather than just some random score. If you look at the FAM or any of those scores like that, I don't know if many of us could just say, hey, this is what the population average is.  So the domains that we're going to talk about a little bit more today that you're going to see, and these are the ones we commonly collect, are physical function, which you'll  see that higher is better, mood and depression. So better mood is higher on the T-score scale, and pain interference, lower is better.  So that's not just a pain number, that's how much pain interferes with the patient. So lower is better. We do have our scores set up in our EPIC. It's a little bit customized.  So up is good in general, just makes it easier to track. So as the pain score actually goes down, the little chart will go up like you saw with what Dr. B showed you guys earlier.  So what's the point of all this, right? What do we do with all these data? We have some good research that's been showing that this data is useful for predicting how  well patients are going to do after surgery or who may be a good candidate for surgery. There's lots of publications out there like this, all peer-reviewed over the course of  the last five, 10 years. And really, if I were to kind of give you guys a couple of little takeaways from a lot  of these, patients that are showing worse preoperative scores are more likely to reach the MCID, the minimally clinically important difference.  So a patient that's doing pretty crummy when they come in, you have a lot of room to make them better. And it's nice that we can validate that with these more objective outcomes.  And patients that are doing really well, well, they're going to be tough to make a whole lot better if they're already doing all the things they want to do.  So it kind of helps you guide some of your treatment with that as well. And we'll go kind of more into a lot of detail with that stuff today. So where do you use these?  How do you use this in your overall picture of the patient, right? You still want to center your focus on the patient visit. You still need a good history.  You still need a good physical exam. You're still going to use your normal x-rays and labs and other tests that may be relevant to that patient's findings.  And all of that is going to be put together for your usual diagnosis and treatment. PROMIS or PROs in general fall into here. They're one of your points of information.  They're kind of an objective type point that goes in with your labs and tests and helps you build your picture of that patient with your history and physical exam.  You can't just look at the score and say, oh, hey, they're doing fine. That's it. You still need to really look at the whole patient and understand where they're coming  from, get your own physical exam findings, really understand them. And this kind of is just one new data point that can really help kind of guide your treatment  and follow your patient along and show them their progress as well. So again, why do we collect these things? And for a patient perspective, what's in it for them?  It's really a way for them to give you information on how their symptoms are doing. It's kind of their way in a way they get to decide based on these data points, if their  symptoms are better with that treatment plan and what's going on, you know, they may say I'm still in pain, but this gives you a better way to quantify it.  It's not just, you know, not that the V.A.S. is bad, but it's a little more data than just the V.A.S.  So it's useful for them because they get to see their actual outcomes and you can show them this on the screen.  It goes right into a record and it's very accessible from from our standpoint. So a patient comes in and depending on what their complaints are, we also can kind of  pick and follow a particular outcome that aligns with their wants and needs. Do they want less pain? Is it a functional problem?  Are their symptoms really just killing their mood and they've been really depressed because they can't get back to their activities?  So, you know, this patient comes in and she says, well, I want less pain. That's what's limiting me here. And, you know, I think this is a this is a new patient.  It's their first time coming in. This is one of Amanda's. I'm going to let her talk to you a little bit about baseline scores here. Yeah, thanks, Dave.  So, you know, I think new patient baseline values are super important and they are a great starting point and really useful because I think sometimes when a patient comes into  clinic and you're kind of looking through maybe all of the things that they've sent to you, it's hard to really understand where where they're at.  I mean, we're kind of getting a picture either from other folks notes or MRIs or X-rays of what we think is important or what we think might be going on.  But this is just another tool to also tell us, man, how much is this really affecting this patient in their life?  So, you know, if this was this was a patient who recently came to see me and, you know, you can look at their depression score, which is that little blue dot up on the top there.  And again, you know, the the Y axis is severity and then the X axis is time. And so that blue dot, that depression score is in the green.  And so, you know, despite the fact that their physical function and their pain scores, which their pain score is green and you can see that that is, you know, they're in a good  deal of pain. They're really moderately affected by this. And when you look at their physical function score, you can see that they're they're not  functioning well due to this problem either. But they're coping because their depression score, you know, is in the green.  So this is somebody who's having a pretty good deal of pain, who's not functioning the way that they should be when matched to folks who are in their age group and their sex.  And so but they're coping with this. And so this this may lead me going in and talking to that person.  You know, it may lead me to be a little bit more aggressive in my treatment algorithm, depending on what they have.  You know, maybe I'm going to spend a little more money and send them to formal PT versus a home therapy program.  Maybe we're going to talk about maybe a little more expensive insert, depending on what they have. So, you know, this kind of baseline really helps just add to the picture.  Like Dave was saying, you know, you still have to look at the x-rays and make the diagnosis and but it's going to guide my treatment plan for this patient.  You know, even if somebody came to me and maybe they had a year of non-operative treatment, this may be a time that maybe we talk about operative treatment, depending on what they  have. So these baseline values are really important. So we kind of touch a little bit more on that just as an example is kind of the same patient here zoomed in a little bit.  So when you highlight these, you're going to get the actual numbers here. As we said, for pain interference, a higher T-score is bad.  This patient's T-score is 64, means they're more than a standard deviation worse than your average age matched control.  So this person's kind of, you know, in your bottom quartile of people in America here for how much pain is affecting them.  So as Amanda kind of said, that's pretty profound and that can kind of guide your treatment.  So in this patient, we may be following that pain because that's really what they're noticing is that everyday pain. We'll kind of walk you through the course of a patient here.  So this is a patient, we're going to kind of go step by step. They started out over here on your left.  They come in and they have, you know, their mood's a little bit down or they're kind of bothered by what's going on.  Their physical function and their pain interference are both down here in the orange. So again, they're kind of more than 10 points away from average.  They're kind of in that bottom third of folks as far as how well they're functioning and how much the pain's affecting them. So they come in and you make your diagnosis.  They have some ankle arthritis. So you treat them the normal way you would initially, they haven't had any treatment yet.  You're going to start with some NSAIDs, you're going to start with some bracing, some different shoe wear options, try and offload the ankle, give them a little bit of time.  You know, we're down here, we check on them six weeks, you know, six, eight weeks later and see where they're at. And you know, they're not doing great.  They're still not feeling much happier about how things are going. They've tried a bunch of stuff now and their function and still going down and their pain is still going down.  So as Amanda said, you kind of change your course here. And we've got some time with non-operative treatment and this has shown that they're not doing great. So what's next?  You know, we talked to them and they decided they want to do an ankle fusion. So at the time of their fusion, appropriately, their physical function kind of stinks.  They're down in the red, but that's because you just used their ankle and they're in a cast and they're non-weight bearing.  So you don't expect that, you know, this data has to be used in line with really what's going on with the patient. Like we said, you can't just look at this single time point.  But their mood's a little bit better, they're kind of optimistic, they had a surgery, their  pain's already feeling better, which is pretty good, immediately post-op, but you know, they're pretty happy right now.  Then you go another few weeks down the road, you transition to a cast, you let them start doing a little weight bearing, they are doing a little bit better, right?  Their physical function's better because they're not completely immobilized, they can at least get around a little better.  Their pain is still feeling pretty good, their mood, you know, they're a little bit still cautious now, they're starting to walk, they're a little concerned how things are going.  But over the next few visits here, you get out of their casts, they start doing some PT, and then, you know, as they go a few months down the road, you see that their function  has improved, and you're back in the green. Your mood is way better than it started, and their pain has stayed nice and stable up here.  So they're actually kind of better than your average now, and that's kind of something  you can track and you can show them, and with more data points, you can show them that progress  along the way, that even if they kind of think, well, I don't know if I'm doing much better yet, it still kind of feels funny.  You show them this little red data point and be like, well, by the questions you've answered,  you can see that you're actually doing a lot more functionally, and you're actually kind of meeting your peers compared to where you started, and that can be really reassuring,  but also help you know if your patients are improving. And this patient, we'll go a little more into detail with this particular patient later,  but it's kind of the opposite experience here, where they started out in a pretty good spot, and then over time, you're really starting to see them drift downward.  This is someone who, we have years of data on them, this is from 2015 to 2023, so it's like eight years of data, and they started in a pretty good spot, but over time, they've  And that is kind of maybe a good time to change your treatment. We'll talk about them a little bit later. So now what's in it for the surgeon?  I want to let Amanda talk to you guys a little bit now, since we kind of know what the patient sees and what the value is for them and how you work that into a patient encounter, to  what we get out of it, what we can use every day. Thanks. So there's a ton that we get out of Promise as surgeons and as providers.  I think the best thing about Promise is that it's a quick, intuitive way to know if our  patient is getting better or if they're not, and that's really going to tailor the discussion. I mean, looking at this graph on the ankle fusion patient that Dave just spoke about,  I mean, really, there's kind of two main points that you've got to know when looking at these graphs.  Up is good, and green is good. So basically, you know, even though we said T-score, you know, a lower T-score  means less pain and a higher, you know, so even though the T-score for pain is inverted, on our graph it shows going up. So up on our graph is good and green is good. So that is,  that's always nice to see and you can pull this up pretty quickly in clinic and get a, get a gist,  you know, understand where your patient's at. So it can improve clinical efficiency.  So we got a little video kind of how we, just showing a couple different patients here that, you know, you pop into clinic and you'll kind of see how things go.  Hopefully you guys can hear. Don't be afraid to turn up your volume a little bit. All right. This person, they're all in the green. That'll take a second.  This patient, also in the green. That'll just take a second. This one, their depression, they're doing okay. They're coping. They're functioning well, but their pain is really  through the roof. That one is going to take some time. We'll see this patient first. We'll be in  and out of there. We'll see this one next and then we'll save some time for this one at the end.  That'll take a bit of time to go through. So that is a real life example of, you know,  kind of what happens in our clinic. I oftentimes will pull up the PROMIS scores to know, you know,  I think that it's important in communication with a patient to kind of align, you know, both of the things that we want to get out of that visit, right? I have expectations and they  have expectations. So it's helpful for me to know, you know, where they're at in their journey.  And the PROMIS scores can really help you with that efficiency. You know, knowing if the patient  is bad enough for surgery, right? I think that Jupo, you and I were just talking about this the  other day. I think you had a runner, a patient who was a runner. Hold on, we'll get back to that.  So, you know, this patient that we talked about earlier, you know, we kind of had this baseline  score, you know, this patient has some, has mild physical functioning and moderate pain interference impairment. And so, you know, this patient, your discussion is going to be  different and, you know, they may warrant surgical intervention if they've had, you know, a year of non-operative management elsewhere and are coming to you, you know,  with these scores. So this may be somebody who, yeah, you know, maybe, maybe it would be a surgical  discussion looking at these scores. Whereas you have another patient, you know, who comes in and  they, you know, they say, gosh, I have, you know, I'm having pain and I can't do the things I want  to do. And this is where Dave and I were talking a little bit about this because Dave, I think you  had a runner. Maybe you want to talk about that. You guys know that type of patient, right? They  come in and they say, I haven't paid when I do things. And then you kind of get these preliminary  scores. It's like something like this on the left side and they're all green, right? They're  functioning. You look at that physical function, they're like the 65th percentile or 65 T score,  which is like 80th, 90th percentile of function. And then you kind of let you really see like,  all right, now let's talk about this. What do you have in pain doing? And you're like, oh,  well, I like running ultra marathons and my feet get sore at mile 60. Well, it's a lot different than, you know, the patient back here who just having pain with everyday walking.  This patient's a lot harder to make better at the beginning. And this is someone where you say,  all right, well, let's try some, some simpler stuff. Maybe it's a shoe wear thing. Maybe we  need a carbon fiber foot plate. Maybe you need a cortisone injection or something, you know,  something small like that. But it's really hard to make someone, as we said earlier, these people  that are functioning well, it's hard to make them better. So expectation setting is really helpful  with these types of things because it really kind of helps you, as I said, your patient comes in  with pain. So it lets us kind of focus on what that pain is and sure they have, you know, it's  their lowest domain here, but they're still above, you know, a T score of 50. So they're still doing  pretty well and they're coping pretty well. And then it'd be good to kind of show them like, Hey,  you're, you're overachieving. And some of these things are, you know, we're not always built for  that. And it's, it's okay to have a little bit of soreness when you do things, but let's not do  anything drastic here. Yeah. So this patient actually had some big tore arthritis, you know,  they're a runner. And so when they came in, you know, you can see they came in quite a few years  ago, they were actually doing pretty well despite you know, having significant pain upon doing  things. And you can see, we tried non-operative management for quite some time until the patient  came in and you know, there, you can see where their scores now have dipped down to a level that  would be appropriate to consider something, something surgical. And so these scores really  help you to be able to manage their expectations around surgery. And I think that that's really  important because you know, that's what we do every day is kind of you know, try to explain,  you know, what people should expect. And the better we do that, the happier patients are. So  that's one patient example, you know, some of these promise scores are really just pattern  recognition. And so this was actually a patient, you know, we've talked about kind of the ankle  fusion and where they were at in their journey and using the promise doors to, to look at that  as well. This is a patient who ruptured their Achilles and were treated non-operatively. And so you can see, come in with severe, you know, physical function is limited, you know,  they have they just ruptured their Achilles, you know, that's a problem, obviously they have  significant pain. And then you get this person out of their splint and into a cast and, you know,  or sorry, out of their splint and into a boot and they start ambulating. And so their physical  function goes up, you know, they can have some dips in pain here in the early on time period, but, you know, overall they do well and continue to do well.  This patient is somebody, you know, looking towards the end of the graph is a, is a post-op  patient. So, you know, looking at more of the tail end of the graph, you can see where the  physical function goes down, the pain is going up and you'll oftentimes see right after surgery  that their depression score will actually improve because they're hopeful about what's to come. And so this is a very common pattern that you see with a post-op patient,  similar to the ankle arthritis example we showed a bit earlier.  You know, just because you have a hammer doesn't mean that everything is a nail. And so sometimes  these PROMIS scores really don't correlate at all. This is a patient of mine who has horrible neuropathy and, you know, his PROMIS scores are all over the place. I don't know  really what to make of them. And sometimes they're just not useful. I find that my neuropathic  patients, they're sometimes not useful. My workers' comp patients are sometimes not useful,  but, you know, sometimes I just, you know, I don't know what to make of this. And so instead  of trying to make everybody fit into a neat little box in our pattern recognition, the truth is,  sometimes it just doesn't fit. So actually Dave and I were talking about this the other day too,  about some insurance denials that we are dealing with and, you know, kind of working on, you know,  as you know, everybody knows how time consuming those can be. And this is a way that, you know,  we can try to improve that process for ourselves. So we can document initial impairment in our  patients and we have an objective data and an objective way to do that. We can say, look,  this is how they're performing with their matched cohort, with their matched population. They are  impaired and they need this intervention. And so it's a nice way to be able to document impairment, document, and, you know, kind of validate what you're doing for those folks.  You also can document improvement. So you can say, look, my treatment worked. This patient  had ankle arthritis. We've used his ankle and he's in the green and, you know, love patients  that are in the green. So I'm fairly new to the University of Rochester and I was very excited to  hear while we were putting this presentation together that we can actually get CME and SAE  credits for doing stuff that we already do. I'm all about maximizing, you know, what we already  do. Dave, I know you just went through this process. Can you talk about that? Yeah. So we  all know that we do a lot of stuff and there's always these increasing demands on us or more  check boxes to click or more forms to fill out. So when you start doing more of these things, we  should try and get the maximum that we can out of them. You know, stuff that doesn't require more  of those mandatory little things you have to do for the institution, anything that introduces new  costs. Why go through another one of those little webinars when you should be going through webinars  like this one that you want to watch? You want to look for opportunities to double or triple  dip into the stuff you're doing. So if you're already getting these scores, if you're already  collating these scores and using them for your patients at University of Rochester, much with  the help of Dr. Baumhauer, we have been able to kind of implement a few nice little programs  just for the stuff that we're already doing for using these PROs, for interpreting these, for  implementing these in our clinics. Some of the stuff we can do is we're actually able to get a  little bit of CME for it, which is nice. You have state requirements for that for all of you that  are board certified, which is hopefully everyone, or at least on that course. You need those for  your maintenance of certification if you're not taking the in-person exams. We've been able to  kind of parlay it into a little bit of malpractice reduction. So our institution kind of requires us  to either do a couple of those kind of institutional meetings that you have to sit through something  for a couple of hours on a Saturday to try and meet some demands for malpractice reduction,  but kind of by showing stuff that, you know, Amanda was talking about, we have information to  show that we're paying attention to where patients are and what's going on and how to really keep  track of their symptoms in novel ways. So we've been able to kind of get the institution to count  that for us. And, you know, you get, as we said, you get MOC credit and you kind of can get a few  other things for these. So it's stuff that you can build at your institution. This isn't all just  out there on its own, but it's just stuff to think about and stuff to think about with any programs  that you implement. Or even if you're the one in implementing this into your, you know, into your  institution, there's probably ways to get CME for that or get other credit from your department.  So just stuff to think about, don't leave stuff on the table. There's plenty of ways to do that  too, but try and get the most out of everything that you're doing, especially when you're doing  it for good reasons and to help out patients and just do a better job as a surgeon. The other stuff  that kind of makes some obvious sense, we've already talked about the research. There's ways  to use this to find out which patients are going to do well with surgery. There's also ways to look  at it. You know, you can make prospective studies, retrospective studies. Do you feel like you do  something a little different or you just came out of fellowship and you have two attendings that do  things really different and you want to find out which way is better? You can, you know, develop  studies to compare those two things. You can just use them a little bit off the cuff on your own to  see which of those patients do better. But it's really a helpful tool to get a little bit more  data besides just your x-rays and the patient says they're doing okay. And for those of you that are  in the early phases of your career, thankfully I am now past my first test in part two, but the  PROMIS is actually used for ABOS part two. So for those of you that haven't collected yet or for  those of you that are collecting for your boards right now, you'll see that you have to input  patient emails and for each of those patients the board actually sends an email to them to reach out which gets initial scores and then at several intervals to get follow-up scores.  We don't know exactly how that's going to parse out in the grand scheme yet, but getting used to  understanding these scores and how things are going and following them yourself is going to  give you a good idea if your patients are doing well. And I don't know, maybe you look at those  PROMIS scores on the patients you get selected that you have to present and that gives you a  little scope of maybe what you're about to get into or questions that the examiners may have for you. So just stuff to think about. It's getting more widespread. There's some other  stuff that's a little outside the scope of foot and ankle for now, but in the hip and knee world  they're starting to require some patient reported outcomes for getting things approved. So just  stuff to think about. It's coming down the pipe. If we know about it, insurance companies know about  it too. So on that note, I'm going to let Dave B. take over here for a little bit.  Thanks, Dave. So one of the other fantastic things about patient reported outcome measures  and PROMIS specifically is that the ability of using them can improve patient satisfaction. And  we all know about Prescani scores and HCaTS scores, and there's a lot of use of those at our institutions. And so if you go to the next slide. So the question really comes down to,  does this information really help? And does it, it empowers patients. It allows us to really see  how our patients are doing, but it can also activate them and engage them in a different way  and really explain to them and show to them that we're listening both to them in the clinic and  also the data we're gathering, we're using that in real time. And so we actually published a  study that looked broadly across orthopedic surgery that really demonstrated that patients felt more in control of their care and showed increased participation with their treatment  recommendations when patient reported outcome measures and PROMIS were used. And that leveraged  the patient experience in shared decision-making, something that's critically important and really  improves the value of care being delivered. And so we took this a step further and actually  recently just hot off the press came up with a new study. And so we'll get to that in a second,  but in the interim, I want to show you just real briefly, there's a lot of questions about how do  you use this in clinic and will this impact my clinic? But I want to draw your attention to this  chart here. The first is that it is incredible how much the University of Rochester has collected  scores over time. So since starting in 2015, there have been over almost 325,000 unique patients and  almost 4.5 million scores collected. But what I really want to draw your attention to is the  median completion time. It takes 40 seconds per patient reported outcome measurement information  system domain. So whether that's physical function, whether that's pain interference,  whether that's depression, each one takes about 40 seconds. That is incredibly brief and something  that can be gathered in the part of routine clinical care that adds value, not just in that  individual patient setting to help you potentially make a decision one way or another, but as we saw  over time, understanding these patterns. And so at the University of Rochester, it's a number of  PROMIS domains that are collected, which we can see here in the different colors for the bars.  But I also want to point out that PROMIS isn't everything. There are non-PROMIS forms as well,  such as the FAM, for example. And depending on the situation being used,  different patient reported outcome measures can be used. The important thing is collecting them  and using them. Those are really important and they can really make a big difference in  your clinical care. And so returning back to this hot off the press study. So we just did an RCT that was based out of the University of Rochester with support from the IOFAS.  And our goal was to say, does the patient reported outcome measurement information system and its  use in new foot and ankle clinic visits improve patient activation experience and satisfaction?  And this is a critically important topic because PROMIS isn't perfect. We love PROMIS. We think  it adds substantial value to the clinical experience. But while PROMIS can add incredible  value, how it does and to whom and when, these are really important questions that we're just starting to unpack. So this study really showed not all patients want to see our graph.  Not all patients want to engage with PROMIS in the same way, nor do surgeons. But understanding  when to use it and how is really, really important. And so if we go to the next slide,  these are the questions we really need to figure out. There's so much PROMIS, if you will, with  PROMIS, but more to unpack. So what foot and ankle surgeons and patient groups would benefit most  from routine discussion in clinic? We simply don't know. There's a lot of kind of variation, as we know, in clinic settings and clinical expectations, etc. And we need to understand  when to use this information. How do we present it? Is the graph best? Are discussions best? Can we delineate which patients want to have a discussion versus be shown a graph?  We don't know that either. And part of this all comes down to health literacy and communication  training. There's a wide range of patients that we see. And to ensure both health equity and  decreased disparities, we need to engage with patients and meet them at their level so that  we can deliver the best care possible. And we simply don't know the exact patient populations  yet. This is a whole line of research that's really, really important. And so while PROMIS  has incredible opportunity and it already shows great PROMIS, if you will, there's so much more to do. And so this is really exciting and incredible area for future research. And so  just in summary, PROMIS and patient reported outcomes in general help in many, many ways.  It puts the patient's voice back into treatment. It aids in understanding patient symptom severity  and allows you to document it upfront in an objective way. It can improve efficiency in  clinic, as we saw with the video with Dave, being able to really delineate, I'm going to see this  patient first, then this patient, and then that patient, because I understand based on expectations  and patterns, which patient may take a long time to engage with. It allows us to double check the  impairment before surgery. Is the patient, quote unquote, bad enough to really benefit from surgical intervention? Again, it provides that documentation for insurers that is really  documented in the electronical medical record, can't really be argued. It gives surgeons credit  for the PRO collection, super, super busy individuals. It's time to double and triple dip and really get the value for the things we already do without doing extra work. And it  improves communications between patients and the surgeon really upfront. And there's so much more to really learn to really optimize this further.  It's truly a remarkable tool that is just one of the tools in our toolkit to really drive high value care.  Action. Okay, room number three, good to go.  We wanna all thank you for listening to us. Honestly, we had tons more videos and we had some outtakes but we cut them because, but we had fun doing them.  I wanna just clarify a couple of things. Dave, you can sort of take that away.  Or add to a couple of things. You know, one of the areas that I have trouble with and I think I'm really good communicator and good listener  is trying to figure out what the patient is saying to me.  So when they say, I have pain and they say, oh, I have pain, I'm here because it's painful. And then you look on it and they're in the green.  Well, they might be having some sort of catastrophizing pain but it's not something we're gonna do anything about. And then sometimes they say, oh, I'm having some pain.  I can feel it. How many times have you heard that? I can feel it. And then you look at it and really they're having pretty significant pain but you would have underestimated it  because they didn't say it in the right way. So really how the patient's affect is and how they decide to share things with you makes it really difficult.  I would tell you this, that when you say to the patient, oh, what I hear you saying is you're having some pain but really your pain is of a degree  that surgery isn't gonna benefit you. People always say, don't patients hate you for that? No, they're kind of thankful. They're thankful that we didn't do surgery on them,  that it wasn't gonna help them. And it's about the delivery and making sure the patient understands that you're watching out for their best interest.  And one other thing I wanna clarify is we talked about press Ganey scores and it might not be important to some, but actually some people told me  that they get their resources taken away if their press Ganey scores are down. So getting higher press Ganey scores and in particular, there's a communication question  in press Ganey. Do you feel as though your provider is communicating well with you? For this provider, that is aligned with good things for you.  It actually decreases, that's why we get malpractice reductions because it decreases litigation risks as long as you're aligned with the patient  and communicating well with the patient. So those are all good things.  Now we have a couple of questions in the Q and A here  and maybe you guys can vote. I don't know if you're seeing them, but it says, I like the idea of, looks like maybe it's Naomi Shields.  I like the idea of promise, but I have several questions. You're at a university with IT support who set up your program to collect  and who reports the data and sets up these charts? What's the cost? And as a non-university private practice person, how do we do this?  I can tackle that if you wish, gang. So first of all, we are a university practice and we did have a custom made platform because in 2015, there was nothing.  So we started that collection phase. But I would tell you that if you go on this website, it's called healthmeasures.net, healthmeasures.net.  You can actually find different ways to collect promise with simple things like a five, I know it sounds like a lot, $5,000 a year,  but it's not that much for being able to use promise on an iPad that you can hand out in your office and get that information. So they do have visuals that are different than ours,  but they have visuals that are quite good at healthmeasures.net. Also Epic, if you have a electronic record, Epic is actually collecting them.  Their visuals aren't as good either, but that's what makes us proud is our visuals are great. So there are different ways. There's even ways to do it for free on the website  if you wanted to. So there are many ways and everyone knows my email. If you have any trouble, just let me know and I'll help you along with that.  The second question is what platform is used to collect promise scores? I assume they're done electronically. And where can I find these questionnaires? Same website.  And anybody want to talk about,  they're electronically collected. So yeah, they're digitally collected. So we do it at, we tested this where to do it. We did it at check-in. We did it in the clinic space.  We did it when they were getting their blood pressure done. And the most efficient way to do it was to collect it when they checked in. Because for some reason they assumed  just like they handed their credit card in or filled out their HIPAA form that they needed to do this promise in order to be seen. So it was an unintended good consequence for us  that it allowed our collection rates to be higher. Anybody want to fill in any gaps that I said there? Yeah, so the collection at check-in is pretty smooth as well.  And I don't know about you guys, but with 40 seconds per domain, you do three domains, it's like two and a half minutes. I try and move pretty quick,  but I very rarely have a patient from check-in into my office rooms in about two and a half minutes. So it really doesn't delay their care  that you get a lot of information in that time. While putting this together, me and Amanda did a little trial run. She put me on as a patient and I went from check-in  through doing the whole promise questionnaire on the iPad and everything like that. We actually videotaped it in case we needed something, but we thought it'd be very boring  for you guys to watch me do a promise score. But it really took under five minutes pretty much from check-in.  You give them your data bar with your info, whatever stuff you need for your office, they hand you an iPad, you go sit in the waiting room.  There's a little basket that you drop it in as they go. If you happen to get them in super fast, we also let them, they can bring it into the room with them.  Like if they get seated in the patient room, same thing, you usually have a minute or two before we pop in. They finish it up and then our techs grab it on the way out.  And ours directly goes into Epic with that. But the collection's pretty smooth with the iPads and if you give them to the patients, they do tend to do them without much issue.  Dave and I, like Dave said, we tested this out and I have the video. It was a minute and 32 seconds. And that was with me, with some input. So it is actually pretty quick  and it wasn't that painful. It was easy to do. Yeah, and there's not much difference. There's a little tiny bit of added time for somebody who has over the age of 80, okay?  But in general, it's not gonna hold you up in clinic.  Dave Bernstein, answer that question about the questionnaires and how are they validated? Yeah, absolutely. So the questionnaires are validated. They were created with support  from the National Institutes of Health in the United States and they're extraordinarily robustly developed and they've been compared and shown to be concurrently valid  with a lot of the traditional measures as well. And so the legacy instruments like the FAM, for example, and so they are certainly validated  and ready to be used in foot and ankle clinics. And I also wanted to circle back real brief also on healthmeasures.net. Electronically and the computerized adaptive tests  are certainly, I'd say preferred and likely a better way to collect problems. But if there's truly a lot of limitations as well, there are static instruments, meaning pen and paper,  the PROMIS Global 10, short forms for physical function and pain interference. So in a pinch, I think it's really important to start collecting PROMs and using them.  Obviously electronic and having them in real time is going to be the most efficient, but healthmeasures.net has all this information  and all of them are validated and ready to be used.  There's a question about if you're collecting other PROs for research, does it create too much work for the patient to collect PROMIS as well?  Well, first I wanna make it perfectly clear that we are doing this for patient care. So we're doing site of service PRO collections. These are just our standard of care.  This is what we do for patient care. And then on the backside of this,  when we have some ideas six months from now, we look at the prospectively collected PROMIS data to apply it to our question. So we don't have an IRB to collect this stuff  because we're actually doing it for routine patient care and you don't need an IRB for that, just like you don't need an IRB to get your blood pressure taken. So that's that.  The second question on this, it says, if you're collecting other legacy instruments like FAM or FFI, well, that is with research.  And honestly, that would be under our clinical coordinators. And then we would have a IRB for that and we would have a different process for that.  So that is not, what we showed you here today is our standard of care. This is what we do every single day. And the comment that was made, it said other PROs,  those other PROs on that graph display that Dave Bernstein commented on, he used FFI and FAM, but we really don't collect that. He was just using that so that we had a reference  for foot and ankle. Really those other PROs are more like Hoos and Coos and stuff like that because our hip and knee guys are collecting that as a requirement for CMS  in order to fulfill their ultimate pay model, which in 2026, they're going to be required  to produce those scores in order to get paid for their hips and knees, believe it or not.  They also have to show incremental improvement in those scores. We're trying to get promised to be an alternative instrument  and I think we will win ultimately for that down the road if I have my way, but I just wanted to tell you  all of that. Dave, did you want to answer other things on this?  I was going to say, I guess if you're already collecting other PROs, maybe that's the question too, is you're using something else. Maybe you're already doing those things.  I mean, I guess what's too much for your patients depends on what you're doing. If you're already doing 15, 20 minutes worth of PROs  and you're adding more, it might become overburdensome. If this lets you phase out some of those other ones with something that's quick and integrates  into your e-record, that might be beneficial in the grand scheme and there'll be a transitional period like anything.  This one is pretty quick, so it's a little bit better for the SF36 or some other things like that  because they're much longer. But too much, I think, is a little bit subjective and it depends on your practice and how things run for you.  And they're concurrently valid with a lot of the legacy instruments too. So there's a lot of concern up front of, well, I've always collected this  because it's specific to the foot and ankle, for example, or specific to another body part or disease or illness. But these are really generalized PROMs  and frankly, patients really care about  their functional status, their pain, and how they're feeling mentally and regardless of the injury. And so these have been shown to capture those domains  and are concurrently valid to those legacy instruments. And so the transition can really improve  clinic efficiency as well in patient care. And these can be across subspecialty too. So this is kind of a foot and ankle group here,  but I'm sure many of you are not a solo practitioner. So if you're really a multispecialty group  and your shoulder guys are doing the DASH score and your hip guys are doing the Hoos and Coos score, then you're doing the FAM score. If you guys can consolidate to one thing  that's valid across multiple domains, I mean, that makes your whole clinic flow a lot easier and gives you guys access to similar information.  So something to think about too is as a group, this sometimes can help you consolidate, which is, again, we kind of talk about that double, triple dip, get credit for what you do,  try and maximize where you're spending your time and money as we have more and more requirements. Yeah, our shoulder guys pick sleep. So there's a sleep domain.  There's like 300 different domains. I keep using the word domain, but really you could call it symptom complexes. So sleep is one of them,  and they collect pain interference, physical function, and sleep because the shoulder, rotator cuff, people complain that they can't sleep because it's aching at them.  So that's why you need to ask the patient, what is it that you're hoping to improve? They don't tell you, I'm hoping to improve my ankle arthritis.  They say, I'm hoping to improve my pain that I'm getting in my ankle or my function of my ankle. And then you know what to pick, and then you know how to track it.  So it really is kind of simple. Early on, somebody asked about OFAR, and OFAR did collect PROMIS, and it did collect some of the legacy instruments too.  And there's a publication by Ken Hunt and others that talk about the relationship between PROMIS and the legacy instruments, and PROMIS did fare quite well in that comparison.  So I'd refer you to that publication if you're interested.  All right, we're gonna go, does anybody have any more questions? Because we're gonna go through one last thoughts from each of us.  So Amanda, what are your closing thoughts for this group?  I'll actually answer it because I think it's a good closing thought. Somebody asked, would you use this if not required? And I will say that since I've been in practice here,  I was in practice elsewhere and I didn't have access to PROMIS, and I was kind of collecting my own patient reported outcomes. And I would say that absolutely, I would use this.  I may not use it on every single patient, but I use it especially if I'm making a challenging decision. Is it time to pull the trigger for surgery?  Am I just not getting a handle on what this patient is saying to me? I just think it's another tool in my toolbox. It's like an X-ray or an MRI,  and it really does help me make a clinical decision. So I don't feel required to use it. I feel like it's a gift that I get to have another data point to help make a decision.  And that's kind of the art of medicine, right? Is making a decision based on all of these data points that we have. And so, yeah, I would use it.  I'm glad to use it.  David Bernstein, you wanna go next? Sure, yeah, this has been fantastic. And thank you all for joining us tonight. It's truly a fantastic instrument  and PROMS in general just really allow you to empower the patient in a different way. And so it gives patients a better way of engaging with you.  And the statement, I have pain or I can't function well, that means different things for different people. And this just gives that additional extra oomph  to really put the patient's voice back into the care that they receive. And I think that's incredibly powerful. And so I will certainly always be using PROMS,  but I've also learned from the best in Dr. B.  I agree that anytime you can give the patient a little bit more input is good. It's very easy for medicine to get a little depersonalized these days  with lots of other demands on us. But also, as Amanda said, it can really help you make the tough decisions. When that patient just like screams  and someone that doesn't need surgery to you and they just demand it and you can put this up and be like, you're doing great. And you told me so.  That is helpful and it puts it there. But also think about it like a test that has absolutely zero risk and almost no cost to the patient. How often do we get that?  X-rays have costs and radiation.  Blood tests have costs and pain and complications. This, you get it immediate. It's a point of care. It gives you information. There's very little cost and risk.  There's effectively no risk to the patient.  It's a pretty darn good tool when you have access to something like that. That risk to benefit balance is really, really leans towards benefit.  So that's kind of another thing to think about too.  Yeah, you know, I didn't see this required question. I'm glad Amanda answered it. You know, it's not required at our institution. It's an opportunity for people to look at it.  And sometimes patients don't choose not to fill it out. And I go to access it and I find that they haven't filled it out. And this is how important it is for me personally  in my clinic is I beg them. I said, please fill this out because it tells me how we're doing with the care that you're getting. And if I don't have it  then I don't really know how to track it. I always say measure and manage, right? Just like you do with your stocks and the stock market  you need to sort of track things and we need to track things in a validated way. And that's what this helps us with. And I really feel as though it's been a great asset also  even though we talked about it not being for research it's been a great research tool as we've looked back on the data to guide patients how much they're going to get better.  So I currently can tell a patient when they come in and they're going to have a bunion surgery I can tell them when they'll be able to get back  to running and jumping with really some assurance because I know what their T score needs to be in order for them to function at the level of a soccer player.  And I've tracked the trajectory of a zillion bunions. So I know when they're going to get there based on their baseline scores. So, I mean, it's really a remarkable tool.  We talk about AI all the time and this is just another one of those really important things. So we're rounding up the hour here and I'd like to thank my three partners in crime here  because we had a lot of fun setting this up  and it was a lot of fun to think about how we use this. So I really appreciate their insights and thank you all for listening to us. Reach out to us if you have any questions  we'll be happy to help you.  Thank you very much.

Video Summary

This video is a presentation on using patient-reported outcomes (PROs) in the clinical setting to impact efficiency, selection, and patient satisfaction. The presenters discuss the use of PROMIS (Patient-Reported Outcomes Measurement Information System), an NIH-supported program that uses validated questionnaires to assess health outcomes directly reported by the patient. The PROs are collected electronically, either through custom-made platforms or using tools like iPads and integrated into the electronic medical record. The presenters highlight the benefits of using PROMIS, such as improving patient engagement and empowerment, aiding in treatment decisions, improving clinic efficiency, documenting outcomes for insurers and malpractice reduction, and providing opportunities for continuing medical education (CME) credits. They also discuss the potential for using PROs in research and the importance of health literacy and communication training. The presenters emphasize that while PROMIS is a valuable tool, there is still much to explore in terms of patient populations, presentation formats, and integration with other PROs. They provide resources like healthmeasures.net for accessing PROMIS questionnaires and encourage practitioners to consider using PROMIS in their clinical practice.

Asset Subtitle

Moderator: Judith F. Baumhauer, MD, MS, MPH
Faculty: Amanda M. Holleran, MD; David J. Ciufo, MD; David N. Bernstein, MD, MBA

There have been many discussions regarding patient reported outcomes (PROs) including what to collect, how to collect, and when to collect these measures. However, real-life examples of the use of these instruments to improve efficiency, aid in patient selection to target improvement, and improve patient education, expectations, and satisfaction have been lacking. In this webinar, faculty will discuss how to align the collection of PROs with their value and use in foot and ankle clinical care.

At the conclusion of this webinar, you will be able to:

Understand the importance of asking the patient to identify the symptom(s) they hope to improve with their care
Align symptoms with a Patient Reported Outcomes Measurement Information System (PROMIS) domain and collect this domain for treatment tracking
Identify the most common PROMIS domains collected in foot and ankle
Understand the use of PROMIS t-scores for clinic efficiency, triage, and clinical care

Keywords

patient-reported outcomes

PROs

clinical setting

PROMIS

validated questionnaires

electronic data collection

patient engagement

treatment decisions

health literacy