Using PROMs in Direct Patient Care
By completing questionnaires on their symptoms and well-being, patients can help clinical teams to improve their care and make services more efficient
Doctors and nurses begin most clinical consultations by asking patients how they are feeling. This gives patients a chance to highlight areas of concern and offers clinicians an opportunity to identify problems that should be addressed.
As clinic time is often limited, NHS Wales is enabling more and more patients to do this in advance of attending their clinic appointment. Some of our services are going one step further: using questionnaires to track patients’ health remotely. Clinicians can bring patients in quickly if their condition deteriorates while allowing others to avoid unnecessary trips to the clinic.
Experience to date suggests this new and innovative approach is a win-win. Patients can have increased contact with services – online, by phone and in person – and spend more time discussing what matters to them. By limiting the time spent on face-to-face consultations that do not improve patients’ health, waiting times are reduced for all and care is focused on those who need it.
Overall, this approach is helping to get better value for the time and resources that patients and services invest in maintaining good health.
Completing PROMs questionnaires
Patients and healthcare providers want the same thing: good health for service users. However, research shows that patients and clinicians sometimes have different definitions of good outcomes. Traditionally, the focus in healthcare globally has been on outcomes defined by clinical experts. In recent years, there has been a shift towards Patient-Reported Outcome Measures (PROMs).
NHS Wales is a world leader in embracing this patient-centred approach. PROMs are widely used in research studies to measure the value of healthcare interventions, including medication, surgery and rehabilitation. NHS Wales is going further by integrating PROMs into direct patient care as part of our Value-Based Health Care Action Plan (2019-2022).
‘People are used to online banking and booking tickets on websites – they expect the NHS to use technology to improve their experience.
Feedback from patients tells us they are happy to provide PROMs provided their answers are used well.
Sarah Puntoni,
Programme Manager,
Value-Based Health Care
Completing questionnaires can take time and effort, especially as patients get used to this new approach. Experience from pilot projects tells us that patients are more positive about PROMs assessments when they know their responses will be used by the doctors and nurses that care for them. Our data and IT teams are developing ‘dashboards’ that will present PROMs visually in ways that track patients’ symptoms and general wellbeing over time. Data will also allow patients to understand how people like them respond to the various treatment options available. This is the path to informed shared decision-making, resulting in better outcomes.
Case study: using PROMs in cardiology clinics
Heart failure patients can complete questionnaires before clinic visits, saving valuable consultation time while being monitored remotely
Heart failure has a significant impact on the quality of life and is associated with poor long-term outcomes: 50% of patients die within five years of diagnosis. As the population ages, the number of people with heart failure rises. This leads to greater demand for services, including unscheduled care where patients are admitted to hospitals through emergency departments. All of this adds to pressure on the NHS Wales budget. It is vital for people with heart failure, and for the wider health and social services, that clinics offer the best value possible.
How it works
Heart failure clinics are embracing PROMs questionnaires to collect information prior to in-person consultations. The service introduced PROMs by asking patients to complete a questionnaire using an iPad in clinic waiting rooms before seeing the nurse. The survey consists of approximately 20 questions covering general wellbeing and issues specific to heart failures, such as fatigue, dizziness and breathlessness. This results in an overall score which gives the clinical team an overview of how the patient is doing, as well as details about areas of concern. This saves time and allows consultations to target what matters most to patients.
Patients can now complete these surveys before coming to the clinic. A text message is sent three days before their appointment. Patients click on a link and answer the questionnaire. Some patients are happy to complete the survey themselves while others need help from a family member or carer. The system facilitates telemedicine consultations if patients need support by phone or cannot travel to the clinic. Telemonitoring of blood pressure, heart rate and weight could also be used to trigger clinical teams to contact patients showing signs of deterioration.
‘PROMs questionnaires can take the pressure off clinic times while improving services to patients. Patients who need to visit the clinic face shorter waiting times, while others can be managed remotely but with the reassurance that we are keeping an eye on them.
Kathryn Roberts,
Clinical Nurse Specialist, Cardiology.
It’s important to educate patients about why we collect PROMs and how we use them. People are happy to complete questionnaires when they see it as part of their care.
Linda Edmunds,
Clinical Nurse Specialist, Cardiology.
This approach can give patients more choice and flexibility. For example, they can check in with us by phone using the PROM. PROMs data also help us, direct patients, to services they may need, such as counselling or physiotherapy.
Karen Hazel,
Clinical Nurse Specialist, Cardiology.
Lessons learned
Using PROMs in direct care requires a cultural shift from staff and patients. Training for staff and support for patients in the early stages can help to secure buy-in as teams and service users transition from the traditional medical model of care towards a more individualised approach with greater shared decision-making. Where this approach delivers clear improvements – such as reduced waiting times or earlier discharge – engagement increases. Getting newly-diagnosed patients to begin their journey with PROMs will add a new level of insights on how patient care can be optimised.
What’s next?
PROMs will be used in direct patient care for a range of chronic conditions (e.g. inflammatory bowel disease) and elective procedures (e.g. surgery). Patient-Reported Experience Measures (PREMs) will also be built into these questionnaires to gain new patient satisfaction insights and to improve service design. Continued support will be needed for staff and for patients, particularly older service users and those whose conditions affect their capacity to complete PROMs/PREMs surveys. This should help to increase response rates.
‘We want the PROMs collection to be integrated into the health system. As patients and staff become accustomed to generating and using this data, and as it brings benefits to direct patient care, this will become business-as-usual,’
Amanda Willacott, Programme Manager, Value-Based Health Care.