No date for the PROM: the association between patient-reported health events and clinical coding in primary care

Paul J Barr,Colleen Ross,Lora Council,Andrea M Austin,Travis D Satterlund,Michelle D Dannenberg,Ariel T Wampler,Scott A Berry,Eugene C Nelson,Deanna B Mcquillan,Wendolyn S Gozansky,Jonathan Skinner,Don Carmichael,Karen E Schifferdecker

doi:10.1186/s41687-020-0183-5

Abstract

ObjectiveIt is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians.DesignWe conducted a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians to identify themes related to the use of PROMs.SettingFourteen primary care clinics in the US (eight intervention and six control clinics), between October 2013 and May 2015.ParticipantsPrimary care clinicians and older adult (≥66 years) patients completing a 46-item health risk assessment, including PROMs for fall risk and UI.InterventionRisk assessment results provided to the clinician or nurse practitioners prior to the clinic visit in intervention clinics; data was not provided in control clinics.Main outcome1) Agreement between ICD-9 codes of fall risk or UI in the EMR and patient-reports, and 2) clinician experience of PROMs use and impact on coding.ResultsA total of 505 older adult patients were included in the study, 176 at control clinics and 329 at intervention clinics. While patient reports of fall risk and UI were readily captured by PROMs, this information was only coded in the EMR between 3% – 14% of the time (poor Kappa agreement). Intervention clinics performed slightly better than control clinics. Clinician interviews (n = 16) revealed low use of PROMs data with multiple barriers cited including poor access to data, high quantity of data, interruption to workflow, and a lack of training on PROMs.ConclusionsCurrent strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; ultimately resulting in underuse. Better systems of presenting PROMs data, and clinician training on the importance of PROMs and their use, is needed.

Highlights

Over 50% of the symptoms and signs of illness go undetected during clinic visits [1, 2]
While patient reports of fall risk and urinary incontinence (UI) were readily captured by Patient-reported outcome measures (PROMs), this information was only coded in the electronic medical record (EMR) between 3% – 14% of the time
Current strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; resulting in underuse

Summary

Introduction

Over 50% of the symptoms and signs of illness go undetected during clinic visits [1, 2]. Patients often report symptoms earlier and more frequently than documented by clinicians; clinicians may be missing the opportunity to intervene early before the patient’s condition deteriorates [3]. This failure to address reported symptoms is especially problematic for older adults with multimorbidity, where early identification of deteriorating conditions is essential to avoid exacerbation of the medical problem and resultant hospitalizations [4]. While evidence of improved health-related outcomes is mixed, [5, 6] recent results in cancer [7] and primary care settings [8] shows that the use of PROMs use in routine care improved health outcomes

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Conclusion