This insightful article, “Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings” by Angela M. Stover, Lotte Haverman, Hedy A. van Oers, Joanne Greenhalgh, and Caroline M. Potter, on behalf of the ISOQOL PROMs/PREMs in Clinical Practice Implementation Science Work Group, provides a comprehensive look into the complex process of integrating patient-reported outcome and experience measures (PROMs/PREMs) into routine clinical care. While PROMs/PREMs are well-established in research for numerous health conditions, their consistent application in daily practice still faces significant barriers. This paper champions the use of implementation science (IS) as a systematic approach to overcome these challenges and enhance the adoption of these vital health innovations.
Key Contributions of the Study:
The authors leverage IS frameworks to analyze and compare four diverse case studies where PROMs or PREMs were implemented:
- Pain clinics in Canada.
- Oncology clinics in Australia.
- Pediatric/adult clinics for chronic conditions in the Netherlands.
- Primary care clinics in Canada, planning PREMs implementation.
These case studies utilized well-established IS frameworks such as the Consolidated Framework for Implementation Research (CFIR), the Theoretical Domains Framework (TDF) [12, 36–38], the integrated Promoting Action Research in Health Services (i-PARIHS) framework [12, 39–42], the Knowledge to Action (KTA) model, and Normalization Process Theory (NPT) to guide their efforts.
Understanding Barriers and Enablers:
A significant finding is the consistency of implementation barriers across various patient populations and care settings. These commonly include:
- Technology limitations: PROMs/PREMs not being integrated into electronic health record systems, or collection systems being difficult to use or access.
- Uncertainty about how or why to use PROMs/PREMs: Clinicians expressing a lack of knowledge on how to interpret responses or discuss them with patients.
- Concerns about negative impacts: Perceptions that PROM use could increase workload, lengthen visits, or decrease patient satisfaction.
- Competing demands from established clinical workflows: Entrenched workflows and competing priorities during limited clinic time.
- Cost and time to implement.
In contrast, enabling factors were context-specific, suggesting the necessity of tailoring implementation strategies to individual clinic resources and local contexts. Common enablers included easy-to-use PROM/PREM technology systems that provided rapid, automatic access to results. Unique enablers capitalized on local resources, such as dedicated facilitators, peer champions, or financial support.
Tailored Implementation Strategies:
The study highlights that implementation strategies evolved across pre-implementation, implementation, and post-implementation stages, influenced by contextual factors. Strategies included:
- Pre-implementation: Engaging stakeholders and clinic leaders, assessing needs, barriers, enablers, and workflow, and developing tailored strategies.
- Implementation: Training clinic teams on using and interpreting PROMs/PREMs, and providing onsite assistance for technology and workflow.
- Post-implementation: Continuing contact with clinics, often through visits, and utilizing audit and feedback with dashboard reports on completion rates, offering additional support as needed.
The Need for Consistent Evaluation:
The paper identifies inconsistencies in evaluation approaches across the case studies. To support standardization, the authors propose specific evaluation metrics for PROM/PREM implementation initiatives (detailed in Table 4 of the source), emphasizing the distinction between evaluating perceptions of the innovation versus implementation effectiveness. These metrics focus on measurable aspects like engagement rates, milestone achievements, and adherence to strategies.
Conclusion:
This research underscores that multilevel IS frameworks are crucial for successful PROM/PREM implementation due to its inherent complexity. While barriers are consistent, the context-specific nature of enablers necessitates tailored implementation strategies based on clinic resources. The authors strongly recommend theoretically guided studies to clarify how, why, and in what circumstances IS principles lead to successful PROM/PREM integration and sustainability. This work is a vital resource for healthcare professionals, researchers, and policymakers aiming to effectively integrate patient-reported data into routine care for improved patient outcomes and quality of life.
Reference: Stover, A. M., Haverman, L., van Oers, H. A., Greenhalgh, J., & Potter, C. M. (2021). Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings. Quality of Life Research, 30(11), 3015–3033. https://doi.org/10.1007/s11136-020-02564-9.
