So, our first talk of this session is titled, Call to Action, Using PROMs for Clinical Transformation, presented by Dr. Eric Mockney. All right, disclosures have already been presented. So, I'm going to do a little quick poll, a show of hands. You're in your office, there's a 51-year-old who shows up with shoulder pain, referred by their primary care physician, x-rays are normal, and they've completed physical therapy, and they had an ultrasound done. The ultrasound shows a deep, partial thickness, bursal-sided tear of the anterior rotator cuff, and no full-thickness tear. So, how many in the audience would do an injection at this point? They failed PT, and the ultrasound shows a deep, partial-thickness tear. Anyone would do an injection at this point? The usual PT, quote-unquote PT, so that's all we know. I did ask him, and he did do a full six weeks, but he did do PT, so anyone would do an injection at this point? What about MRI? How many would indicate for surgery? What if I told you that his patient-reported outcome scores at that time were totally normal? Would that change anything? Now, another patient, this was probably a couple months before that, 70-year-old coming in to schedule bilateral shoulder replacements. He's coming in to schedule, this is their third opinion, and I guess my question is, would you schedule if his patient-reported outcome scores denoted only mild symptoms? So, you see where I'm going with this, right? This is where PROMs come in and move out of the research realm into the real-world realm, and it's not just about saying no to surgery, no to utilization. This happens a lot, too. Patients come in after surgery, and they want to know how they're doing, because they can't really remember how they were doing before surgery, and so we have tools now to show what changes are in physical function in real-time monitoring, and this is another application where PROMs can go, and again, the theme here is to make PROMs clinically relevant and out of the research realm, they have to have a few factors. You have to have the data in real-time, meaning that when the patient is in front of you, this information is needed to inform, educate, and monitor. Secondly, it has to be actionable. If you don't have the data in front of you, and you don't know what it means, you can't make decisions. So, for the first patient who came in with the normal PROM scores, I told him, just go home, do some exercises, and you'll be fine, and he was happy with that, and so there's often a disconnect in what they're doing as a treatment, and what they're getting, and what their scores are, and finally, it has to be high-fidelity. If you're capturing PROMs on 20% of the patients, or 30% of the patients, or on two of the ten clinics in the practice, there's going to be very limited utility. So these are the three tenets to make PROMs clinically relevant, and you're going to say, well, that seems hard to do, to get all those factors, and it is hard. At Henry Ford, we're a large corporation. You've got to have all the puzzle pieces working together, and if you're a solo practice, it may be somewhat more manageable to get the puzzle pieces together, but you have to figure out yourself, and so leadership, practice management, IT, operations, workflow, and clinicians all have to buy in, and we're not going to go over how to get that together. We've published on that, and I'm happy to talk about that offline, but there have been blueprints described, not just by us, but by many, on how to get PROMs into daily practice. So what I'm going to share in this very short time is where we can take PROMs out of the research realm. Now, all of our research talks were great, and it shows the power of, you have to have PROMs for clinical research at this point, but there are other applications. So at Henry Ford, we have 75 orthopedic surgeons and 60 advanced practice providers across five hospitals and 30 clinics. What we did was, we said, well, why are we asking the same questions on intake? How did you get hurt? What's your pain score? Did you take, did you try physical therapy? Are you on opioids? Who referred you? What's your occupation? We all asked the same thing. So what we did was, in our PROM pathways, in our ambulatory setting, we just made one intake form and give it to all new patients that automatically document in, so overnight, we had an entire service line of thousands of pages of paper go away per day, so we can go totally virtual, I'm sorry, totally paperless by using PROMs to our operational advantage. The other thing that's happening now is there's a big emphasis on experience, PRESS Ganey, LeapFrog, CMS star ratings. This is getting more and more important, and as surgeons, we don't have a lot of control sometimes on outcomes and how patients do, but we do have more control on experience. This was a study out of Rochester with Dr. Judy Baumhauer that showed PRESS Ganey scores actually improve when you review PROM scores with patients. This is a huge deal to all kinds of practices and systems. When you think about our move to value-based care, as we move towards more of a population health perspective, as I mentioned earlier, we are going to start getting paid to make people better, not to do surgeries, and there's a concept that's been around for 10 years now on integrated practice units, and these are basically teams of clinicians that treat patients based on their patient and not their condition, so when a patient comes in, they'll see a nutritionist, a psychologist, a social worker, physical therapist, and clinician at the same time to make sure we treat them from all these angles, which we know contribute to their pain and morbidity. If you have PROMs up and running, you're able to do some of these innovative measures, so we did a pilot study. These are patients with chronic back pain with a BMI over 35. This is the hardest population to treat, and with an eight-week intervention of two visits, and we measured function, depression, pain catastrophizing, fear avoidance, quality of life, we found that we could move the needle on all of them, and what really mattered was the pain catastrophizing and the quality of life and the fear avoidance, and the other thing we did in an orthopedic-led clinic, we made referrals to sleep medicine, nutrition, chiropractic care, massage treatments, behavioral health, and acupuncture, things that are not typically in our bag of tricks, but we now can do that by looking at PROM scores and applying them to real implementations. You saw this slide earlier, so the payers are now catching on to this, right? They know as a field we are doing too much surgery, and that is really hard to refute, so CMS going forward, and it's in the proposed rule change now, phase now, but it will be most likely approved. We are now going to be required, after a few years of observation, to start collecting PROM scores at the hospital level for total joint replacement. This is just starting, and it's going to get more and more, and what happens when you start focusing on clinical care through PROMs, a lot of good things happen, so at Ford now, we have capture rates of over 80 and 90% of our PROMs across all patients, thousands of patients a day, 84% of our documentation has PROM scores in them, so when you see a note from our practice, you're going to have PROM scores in them, 82% of our providers now say they use PROMs for shared decision making. That was 0% before you started collecting PROMs in real time. We're doing real-time intervention on depression screening and reaching out to patients in real time that day if depression scores exceed thresholds. We've gone paperless, as I mentioned, and we're now able to do all kinds of value-based innovation implementations based on PROMs by having this in place. So in conclusion, PROMs must be available at the time of the clinical encounter to make them useful and meaningful. Having after-the-fact doesn't really do much except from a research or reporting perspective. There's a lot of non-research applications that I've highlighted here today, and of course, the research gets much better as well. Thank you.

Dr. Eric Mockney

Call to Action

PROMs

Patient-Reported Outcome Measures

clinical transformation