January 14, 2026
5 min read
Click here to read the Cover Story, “Lab to clinic: Patient-reported outcomes individualize care.”
Measure PROMs to manage outcomes
To say “no” would be to ignore the fact that we have been collecting patient-reported outcome measures for more than 10 years.
This effort began in orthopedics as a small pilot project at my institution. Within 3 weeks of launching the pilot with a few willing divisions, the process proved so successful that we opened it to the entire department. It requires prioritization and a unified commitment from clinicians and providers across the health system, but it is absolutely achievable.
That said, the devil is in the details. The PROM we ultimately adopted was the patient-reported outcomes measurement information system (PROMIS). PROMIS focuses on symptoms, which aligns with why patients seek care in the first place: to improve pain, function and other symptom burdens. PROMIS is particularly well suited for use across a health care system because it is a single deployment platform with more than 300 validated symptom assessments — known as domains — and multiple languages. Scores are reported as T scores, and data collection is efficient through item response theory using computerized adaptive testing.
Judith F. Baumhauer
PROMIS works well in orthopedics, but its value extends far beyond our specialty. The same PROMIS platform can assess symptoms such as sleep disturbance, cognitive function, anxiety or self-efficacy in other clinical settings. These results can be viewed in the electronic health record at the time of the visit, making it actionable for clinicians. That same infrastructure can then be used in clinics, such as dermatology, simply by selecting different symptom domains. This is how PROMs can truly move across an entire health system.
One of the major concerns clinicians raise is the growing linkage between PROM collection and payment. Many worry that the PROMs collected now for joint replacement and tied to reimbursement do not reflect the improvement seen by the patient. It may be because CMS has chosen specific anatomic PROMs to assess outcomes after joint replacement surgery. There is currently no flexibility to use alternative instruments that could be crosswalked to these anatomic measures, such as PROMIS. Compounding this concern, the vetting process for these anatomic instruments was not open or globally inclusive.
PROMIS has been widely adopted in orthopedics, and many orthopedists are far more familiar with it than with instruments such as the Hip Disability and Osteoarthritis Outcome Score or the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement. Yet clinicians are now being asked to collect, interpret and be judged solely on these anatomic measures. This is challenging because many surgeons do not know how to interpret HOOS or KOOS JR scores at the level of an individual patient, and that discomfort is amplified now that these measures are tied to reimbursement. CMS will likely need to revisit these decisions and consider allowing other validated instruments to contribute to outcome assessment, so clinicians can feel confident that we are measuring what truly matters to our patients and doing the right things for their care.
I often return to the age-old adage: if you do not measure it, you cannot manage it. Orthopedic surgeons frequently say, “I know my patients, I know they are improving.” And while we do listen carefully to our patients, the reality is that we do not ask the same questions, in the same way, at every visit when it matters most for their care. Without that consistency, variation in care is inevitable and often invisible.
You cannot truly understand variation unless you are asking a consistent set of questions through time. My hope is simply that we achieve greater consistency so patients can better understand where they fall in terms of symptom severity and what response they might expect from a treatment or surgery we offer. If we improve consistency, we can reduce unwarranted variation and, ultimately, decrease health care costs while improving patient-centered care.
For more information:
Judith F. Baumhauer, MD, MPH, is a professor of orthopedic surgery and vice dean for academic affairs at the University of Rochester School of Medicine and Dentistry. She wishes to be contacted through Barbara Ficarra at barbara_ficarra@urmc.rochester.edu.
PROMs collection presents with challenges
The easy answer is “no” for multiple reasons. Number one, and probably most importantly, is cost. There are obviously some large academic institutions and health care systems in the United States that probably have the infrastructure to put such tools in place. But the reality is, when you look at the majority of midsize or smaller hospitals, not to mention independent groups or private practice groups, they just do not have the means to implement that type of infrastructure and technology.
Carlos A. Higuera-Rueda
There are a couple of independent large organizations and other groups that represent physicians that have looked for answers to that question. The American Academy of Orthopaedic Surgeons has some resources that are relatively affordable to implement in your daily practice. They are not free, but such resources make it easier than trying to implement these tools on your own. Moreover, this is where federal or state initiatives can potentially help. There are some initiatives from CMS that provide resources for this type of infrastructure.
Another barrier to utilizing PROMs data for screening at an individual patient level is the diversity of the population that we help. We have a fair number of patients who speak a first language other than English or have cultural barriers that limit the usefulness of questionnaires as tools for initial assessment. This, for example, is a significant limitation in my own practice in South Florida where we have a large Hispanic population. Sometimes they may not fully understand the questions even when they are translated. In addition, some patients are elderly or otherwise not equipped to navigate an electronic tablet to answer questions. Of course, one option would be to have a navigator to assist with collecting the information, but this option tends to be very costly. Validity of the tools is another challenge. Despite the abundant peer-reviewed literature showing that questionnaires can certainly measure pain and function, there is an inherent limitation in most PROMs tools in terms of the objectivity of the measurement. And there are some peer-reviewed studies that show that results ultimately depend on the mindset, mood and level of attention that the patient has when they are answering the questions.
Lastly, there are some discrepancies when we are measuring pain and function between the different PROMs instruments that are available. I have significant concerns about making reimbursement and policy changes based merely on PROMs. While it is true that they are better than just relying on how we as physicians say the patients are doing, due to the important limitations mentioned above, it is risky to make important decisions like reimbursement merely based on PROMs tools. There may be opportunities where we have some combination of PROMs and objective measurements from the physician. For example, when measuring knee function, both range of motion and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement can be used in conjunction. It would be ideal to have a mix rather than just relying on PROMs to make final determinations of how the patients are truly doing in terms of pain and function.
For more information:
Carlos A. Higuera-Rueda, MD, FAAOS, is the Amy and David Krohn Family Distinguished Chair in Orthopaedic Outcomes and director of the Levitetz Department of Orthopaedic Surgery at Cleveland Clinic Florida. He can be contacted at higuerc@ccf.org.
Sources/Disclosures
Source:
Expert Submission
References:
Disclosures:
Baumhauer reports being a board member for the PROMIS Health Organization. Higuera-Rueda reports no relevant financial disclosures.
Ask a clinical question and tap into Healio AI’s knowledge base.
- PubMed, enrolling/recruiting trials, guidelines
- Clinical Guidance, Healio CME, FDA news
- Healio’s exclusive daily news coverage of clinical data
