Patient-reported outcome measures may be integrated into virtual orthopedic care
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The COVID-19 pandemic forced many orthopedic providers to embrace virtual care as part of their daily clinical practice.
However, it has been shown that remote monitoring of patient-reported outcomes measures (PROMs) may be done in conjunction with the virtual orthopedic care provided to patients during and after the COVID-19 pandemic. Furthermore, PROMs used in this way support an accurate pain and functional assessment.
To be successful, a virtual visit must allow the provider to effectively communicate with the patient and perform a thorough visual physical examination. However, as is done during in-person ambulatory visits, the provider must also understand the true functional capacity and symptom severity of the patient. Traditionally, this is achieved using PROMs, which are validated questionnaires that report health as perceived by the patient. While traditional paper-and-pencil questionnaires are not amenable to virtual care visits, unless questionnaires are physically mailed to and received from patients, the provider can seamlessly integrate electronic PROMs into routine virtual care. Such PROMs collection serves as a valuable augment to the history and physical examination performed virtually.
Questionnaires completed before virtual visit
To be most useful, the PROMs must be completed prior to the virtual visit, as data from these questionnaires can then be easily incorporated into shared decision-making with the patient. For many providers who already collect electronic PROMs, remote administration can be effectively performed through most PROM platforms. These questionnaires can be electronically delivered through the platform’s patient portal or through an email to the patient.
Although remote PROM administration has demonstrated success with regard to patient compliance, providers or their staff may have to send reminder messages or phone calls to ensure patients have completed the questionnaires prior to the virtual visit. When collecting PROMs remotely prior to the virtual encounter, the provider can anticipate how well the patient is doing from a functional and symptom perspective and target the encounter appropriately. Pre-review of PROM data can also enable a more efficient virtual encounter.
Providers who do not typically use PROMs can incorporate these into virtual care visits through a number of mechanisms. Many electronic health records are already integrated with PROMs. These may include diagnosis-specific measurements and domain-specific measurements. The provider should consult the practice’s information technology team to determine which forms are readily available for use and how these can be administered to patients. Fortunately, there are many options for PROM administration independent of the provider’s EHR. Many PROMs are available online and can be administered by phone by the provider or a member of the staff. The scoring can be incorporated into the encounter note and, more importantly, into the virtual care visit discussion with the patient. Alternatively, the provider can complete the questionnaire with the patient during the encounter, which also enables real-time review of the PROMs.
If the provider does not have a particular PROM in mind, there are many general forms that are suitable for most patient types. One that is particularly useful is the NIH patient-reported outcomes measurement information system (PROMIS) Global 10, which is a free 10-item questionnaire that reports a physical and mental health component. These forms and score outputs can be accessed online. As with all PROMIS measures, scores are reported as a T-score metric. Scores of 50 generally correlate to those of a reference population.
A particularly efficient PROM is the single assessment numerical evaluation, which is a single question that asks, “How would you rate your [joint of interest] as a percentage of normal, with 100% being that of a normal joint?” This single-item questionnaire has shown favorable correlation with lengthier PROMs for various diagnoses.
PROMs impact screening, follow-up
When used as a screening tool during virtual care visits, PROMs can help a provider determine if an in-person visit is necessary. For example, a patient with a shoulder injury after a fall who has near-normal PROM scores and relatively preserved range of motion may have sustained a contusion or sprain that warrants a follow-up that takes place within a reasonable, but not urgent, time interval. Should that same mechanism of injury be associated with a limited range of motion on active testing and high levels of pain and functional impairment as measured by PROMs, it may require the patient undergo early intervention (eg, screening ultrasound to rule out full-thickness rotator cuff tear). By this same measure, if the patient has improved range of motion and PROM scores at a virtual follow-up assessment, the need for in-person monitoring may be minimized, with the decision made in conjunction with the complete clinical picture.
Patient-reported outcome surveillance with remote monitoring may also limit the need for routine follow-up of patients after standardized surgical procedures (eg, hip and knee arthroplasty). Recent literature has demonstrated reliable plateaus of PROM improvement between 3 to 6 months following total knee replacement. Therefore, patients being seen for virtual care visits due to the COVID-19 pandemic who are in this “plateau” window and who have favorable PROM scores may not require in-person follow-up, even after return to normal ambulatory clinical operations. Moreover, virtual or remote PROM screening postoperatively may lead to permanent workflow changes in the postoperative care of these patients, which would reduce low-value-added in-person clinical visits for both patients and providers.
Summary
Successful integration of PROMs into virtual care enables accurate assessment of pain and functional status in patients and allows for streamlining of patient care operations, such as through efficient screening of new patients and routine postoperative monitoring of established patients.
References:
Austin DC, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.07.023.
Borowsky PA, et al. J Am Acad Orthop Surg Glob Res Rev. 2019;doi:10.5435/JAAOSGlobal-D-19-00038.
Gowk AK, et al. J Shoulder Elbow Surg. 2019;doi:10.1016/j.jse.2019.04.041.
Kagan R, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.03.020.
O’Connor CM, et al. Arch Bone Jt Surg. 2019;7:303-306.
Tanaka MJ, et al. J Bone Joint Surg Am. 2020;doi:10.2106/JBJS.20.00609.
Torchia MT, et al. J Arthroplasty. 2020;doi:10.1016/j.arth.2020.01.015.
For more information:
Antonia F. Chen, MD, MBA, is the director of research for the division of adult reconstruction and total joint arthroplasty in the department of orthopedic surgery at Brigham and Women’s Hospital. She can be reached at 75 Francis St., Boston, MA 02115; email: antoniachen1@gmail.com.
Eric C. Makhni, MD, MBA, is a board-certified orthopedic surgeon at Henry Ford Health System Orthopedics specializing in sports medicine and joint preservation of the shoulder, elbow, hip and knee. He can be reached at 1961 S. Telegraph, Bloomfield Township, MI, 48302; email: ericmakhnimd@gmail.com.
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Austin DC, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.07.023.
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