The Clinical Importance of Patient Reported Outcome Measures

It is critical for the therapist or healthcare practitioner to go through the PRO with the patient in an item by item fashion. Otherwise people generally view them as just another piece of paperwork. When used and administered properly they are an amazing tool. Nice post!

I think the whole industry gives our pts much too much paper work to fill out. FOTO was lame. Saticfaction forms makes me feel like am going to a chain restaurant. Know your pts and you will their progress.

Bruce,

I agree with knowing your patients to see if they are progressing. PROs however, give both insurance companies, the physicians of the clients you work with, yourself, and your patients a visual confirmation that they actually are getting better. I think most importantly is that it help the reimbursement from insurance companies and helps to motivate patients.

I think that the presentation of the PRO must be explained and thought of as a TOOL vs. a PAPER. When utilized as a TOOL it can tell us alot about a patients level of function and progress from our interventions. Great topic Philip!

Bruce, I will have to full-heartedly disagree with your opinion. Clinicians may think they know their patient’s progress, but they don’t know it unless they measure it. The tools are just paperwork if they aren’t analyzed or utilized for clinical decision-making. They are a complete waste of time if the information within them and from them is ignored.

Here in the States, as the times continue to change and as comparative effectiveness studies will be underway – our profession will need data – data to support the effectiveness of our interventions. We will need data to inform stakeholders about the cost of services and the quality of life from the services. We can’t do this based on opinion.

FOTO isn’t lame. FOTO is finally beginning to define scores and is beginning to define minimally important clinical differences. That’s some pretty good stuff to know when it comes to outcomes. FOTO also has the capability to compare an individual clinician’s performance nationally. Quite a bit of the outcome literature here in the States does use the FOTO database. I don’t believe it is fair to state FOTO is “lame.”

Philip has done a ton of work on outcomes. He uses different tools than we typically see in the States. A platform he has designed is a web based tool that not only captures outcome information, but also projects a prediction as to when the patient will be 80% of “normal.” You can find it here: http://www.adviserehab.com/ His tool has an interesting twist of having the capability to predict. I, personally, am captivated by the use of statistics and numbers and how these can be used to help clinicians.

We should want information on our outcomes and we should want some type of tool to be used to capture this information. Business owners are always interested in the “health” of their business and always thinking of ways to increase productivity… shouldn’t we as clinicians also want to know the “health” of our performance?

Snippet
You are welcome to stop by my office and convince my highly trained and talented staff of PTs FOTO is not lame. This “tool” was forced on to us by PTPN and we think it is a waste of time. Does your office diligently use this?

My PTs have put together a FOTO statement.
In the world of health care and, more specifically, physical therapy, we all strive toward a good outcome for our patients. This requires the healthcare practitioner to use knowledge obtained through our formal education, ongoing continuing education and even previous experience. A great deal of time and research has preceded FOTO specifically regarding the development of “best practice” within evaluation and treatment technique(s). The improvement/change in patient dysfunction to function has always been the desired outcome. But with FOTO it appears that patient “satisfaction” with our facility has taken the limelight. Treatment must be individualized to each patient’s specific problems, taking into consideration their physical status, therapist and patient goals and co-morbidities. Why is it important to categorize outcomes by a specific diagnosis? We need to treat the patient—NOT their diagnosis. The diagnosis is simply a starting place for understanding what the patient is presenting us in the clinic. Many patients have to participate in aspects of therapy that they would not necessarily do on their own. We are not here to be “popular”, but to make a difference in the physical state of our patients. Let’s leave the survey taking to local restaurants.

Philip,
I took a look at your software and I find it very exciting. I believe that as PTs, we give very generic (and poor) prognosis of recovery because there aren’t many ways of giving an accurate one(besides CPRs). I believe if PTs dont utilize functional outcome tools or webdbased tools such as this, they will not have the same results as those who do and won’t be able to predict the outcomes of potential and current patients.

If you were a physician, would you refer to a clinician who has cutting edge techniques and is able to give an accurate prognosis based on presention or refer to the one who says those tools are lame and they dont need to use anything to predict outcomes??? Or as a PT, would you refer your patient to an orthopedic surgeon who is using old techniques or the one who is using cutting edge and measures his patients outcomes???

Just something to ponder…

It is great to see input, comment and ‘debate’ in this normally rather dull field of health.
I fully understand Bruce’s comments and opinion on FOTO, as the system addresses aspects different to that of most clinicians, has a financial driver and vested business interest behind it with political support that the daily patient and clinical is not always comfortable with.

It is not a question of being up to or out of date, new technology and ideas are a supplement to good clinicians – they provide the 3rd arm of evidence – the clinician, the patient and the external research.

Perhaps Bruce could look at the software alternative we have worked on, http://www.adviserehab.com, that works via IE and firefox, not Safari, to provide a patient and clinician focused method that may be of assistance to him.
If the IT aspect is not for him, there are simple paper versions that take less then a minute to complete and 10 sec to score – they are available via PT Project.

Thanks for the input and comments – I have been at the World LBP congress in LA .

In response to Chris – going through the PRO with the patient can bias the input and the result. Ideally they should complete it themselves to give a valid response – however as you inferred – you can assist in explaining the different items / questions / constructs but they must complete it

For Bruce – I’d reinforce Ryan’s comments – A quick easy to use tool provides quantified and valid documentation of the patient and their progress. As a therapist you don’t need to do these on every patient – but for those with a 3rd party payer or long rehab over multiple weeks or months, it provides quality assurance. A baseline at start then a weekly or fortnightly score – a good tool will take < 1 min to complete and < 20 sec to score

This supports Joseph's input – determination of change in function is critical in justification and accountability for a provided intervention.

Where are you located, Bruce? Sounds like the whole problem was the system was forced onto clinicians… it’s never a good thing to force change upon anyone without input, discussion or learning the value of what is being desired. FOTO isn’t lame. Now, with regard to the FOTO reports – I think the reports could have much more eye-appeal and be much more user-friendly. The information is there, but it isn’t presented in a nice, easy to understand manner. I have shared my thoughts and actually provided some recommendations on how to change FOTO reports to be more useful for clinicians with the FOTO group. I’m just one voice though.

I hope I am not spreading rumor… but I also swear I remember reading somewhere… something with McKenzie assessment methods and FOTO were used during discussions with a third party payer to negotiate a provider’s contract. The data helped improve reimbursement. Data is not lame.

I could try to comment on the PT statement on FOTO, but I’m a bit lost. Bruce, what do they mean by “patient satisfaction with our facility has taken the limelight?”

Outcomes have to be categorized in some manner in order to compare. The CAT (computer adaptive testing) used in FOTO is anatomically, regionally based. Each CAT is specific to the reason for physical therapy. If the tool were some huge generic tool, what you would have would be “OPTIMAL” crap ( http://tinyurl.com/2fnb5qb ) and the huge assessment tool created by RTI for DOPTA http://optherapy.rti.org/AssessmentTools/tabid/74/Default.aspx The likelihood of learning anything about the value of physical therapy will be lost with such generic tools because there will be no way of knowing if clinically relevant change even occurred and the amount of change will be different for each population/diagnosis. In other words, in my opinion, the folks who designed OPTIMAL and the consultants who designed the DOPTA assessment tool have wasted time and money.

Patients are treated – diagnoses are not treated – I agree. Diagnoses are descriptive or categorical pieces of information to better understand the final results.

What’s more important than “satisfaction” is customer loyalty. Surveys don’t capture loyalty.

Sorry. I put the satisfaction thing in because that was the next mandate that I hate that PTPN demanded us to do. First FOTO next year satisfaction surveys. All means the same to me. More forms and papers. Neither very helpful. Paper compliance to stay in the game,not to play the game better.

So, Bruce… what method would you propose to “play the game better?” How would you prefer to determine who “plays the game” the best? And with what you propose to be better – how will other stakeholders perceive and use your preferred method?

End referral for profit and we will know the best PT practices by pt selection!

So, doctors and their conflict of interest goes away – okay, that would be a great thing for consumers, stakeholders and our profession. And then, you want to put the choice into the hands of patients. Okay… how do patients choose? We have the “phone book” approach… and the “Find a PT” approach… and of course, word of mouth. Have you ever met a physical therapist who didn’t believe he or she was good or didn’t believe he or she provided excellent care?

So, you propose our profession stay at the guru level? Have you thought of other things patients choose – like: http://crispian-jago.blogspot.com/2010/10/handy-alternative-therapy-flowchart.html Do consumers really know how to choose well? Do you think we as a profession and as individuals could provide information to help consumers make a good choice when choosing a physical therapist?

Have you really thought about the issue, Bruce, or are you letting your dislike for mandates cloud the opportunity for deeper thinking on the subject?

Snipppet
Truth be told. word of mouth and or guru approach has served me well.
Get rid of conflict of interest and I will gladly fill out forms that compare best practice performance. Until pts known about financial conflict of interest between providers we can not compare anything.
I will fill out any forms that are mandated to help me help my pts.

HEY!!!!! GREAT DISCUSSION SO FAR!!!!!!!!

Bruce, Bruce, Bruce… you are waffling! Why would getting rid of conflict of interest be the impetus to change your position on outcomes?

You know, sadly, we should want to elevate ourselves and this profession to a level higher than guru and word of mouth. We should want to do whatever is helpful in measuring our results AND we shouldn’t wait for the whatever to be mandated. We should try to lead and demand what is necessary for us to demonstrate the value our profession brings to the table. By the time something is mandated, those other stakeholders hold all the control in determining final decisions without our clinical input. Personally, I envy you are mandated to use FOTO. Here in Michigan, Blue Cross has been playing the “how low will you go” by defining quality solely by number of visits and categorizing providers based on the number of visits. There is no “quality” in what Blue Cross Blue Shield monitors – and they won’t listen to a voice of reason on what should be included in determining quality.

The manage care companies will not change based on a new form. They will use outcome against use. Too much improvement not covered. Not enough improvement not covered. I was a network head twice and from inside info it is not the pt improving it is about controlling cost. It is not PT saves money by avoiding other services. It is deny any services they can.

Get rid of referral for profit and you get rid of cheap bottom sucking PT. Hard to do a $ 25 PT visit and help the pt have a good outcome. In Miami the POPTS stim and HUM all day long and it is cheap to produce. Then they wind up at my office a mess. Benfits exhausted and paying out of their pocket. I have do a good job as the independent,guru, word of mouth go to PT.

Okay… now you have a point on outcomes being used against us. I do have a bit of fear about that aspect. The reason I have some fear with regard to being used against physical therapists is because not enough of us professionally are using outcome tools, so we are less knowledgeable about our outcomes and even expected outcomes – which means the payer again has full control in determining quality. At the same time, I’ll waffle on my thoughts – as you say, the payer often times only wants to pay less and less so the CEO gets more and more. If that type of mindset is what inherently determines decisions, very little can be argued to improve our negotiations – unless we can show big, picture cost savings long-term and keep that first and foremost in our negotiations. We don’t have that kind of data yet either. Although this aspect of the argument sure creates a bleak picture, if we put the patient as our primary focus, is it the right decision to ignore the value outcome tools may have in our interaction with patients? Can the information gained from the tools help us to improve our services and can the information be valuable for patients? Our profession doesn’t make it easy for patients to compare providers… but I have actually been finding that my patients even after word of mouth will choose me over a competitor because of the information I have on my website – outcome information. They like it – they like that if they call, I will get on the phone, answer their questions, ask a few for myself and be able to give a guesstimate of number of visits and cost for services – all based on outcome data. Just to open your mind a tad… I’ll share what I share openly and transparently with patients and potential patients: http://www.redcedarphysicaltherapy.com/2.html

With regard to POPTS. You know what’s really crazy? Any business focused on stim and HUM is focusing on making a buck off the lowest paid CPT codes. The data, from outcome research using outcome tools, is already published informing whoever cares the lack of value and the negative benefits from those particular passive interventions for certain conditions. http://blog.myphysicaltherapyspace.com/2009/05/ultrasound-yes-no.html

Bruce, have you ever wondered if you could perform better? Have you ever wondered if you changed certain aspects of your interventions/approach that maybe patients might reach their final performance and goals sooner? I will agree, whenever anything is mandated without discussions or a mental buy-in to the change, a huge negative feeling happens toward that change… you now have something valuable in your hands – information. You have the capability to now self-reflect on your clinical practice and you have more than just your thoughts to substantiate your performance – you have data. You can take that data… you can use that data to grow, learn and change if necessary. You can use that data and present it in a manner that easily and readily speaks to consumers. You can set yourself apart from the norm even more…. a guru with data gives me goosebumps! Your credibility is substantially enhanced and what if… what if you didn’t have to clean up “messes” any more and you were chosen and even demanded first? How fun and cool would that be?

Great Input from Bruce and Snippets, – the others seems to have slowed!
Bruce has a very valid point. Within insurance the term is ‘profit premium ratio’. Provided the premium is high enough to make a profit, everything else for quality is not worth while – even though it may provide savings via identification of trends, service efficiency or inefficiency. That aspect is just ‘too hard’. So one argument, as stated by Bruce, is that you are just fighting a loosing battle no matter what you do. However, there seems to be a trend over recent years to consider outcomes within the aspect of the patient, that this indicates progress and satisfaction and the resultant improved cost efficiency. For the patient it provides motivation and feedback that helps you professionally.
By using outcome tools that require minimal to no therapist input – eg the software types completed by the patient on a tablet or a PC – the efficiency improves.
In our clinic we don’t use outcomes for every patient, we use these forms of outcomes only for compensable patients, workmans comp, or those where the account is paid by a third party. For private patients with a likely longer recovery time frame – then usually on the 2nd visit.
Perhaps Bruce could logon, try it and see how it goes.
There is a temporary free access login and password – http://www.adviserehab.com username: ptproject login ptproject.

Physiophil

The PT Project
Over the weekend I searched and found the perfect link on medical forms.
http://www.xtranormal.com/watch/6868901/
It takes 4 minutes but is worth it. Watch the whole thing.
For humor’s sake substitute DPT for Vet!