Seamless Integration of Computer-Adaptive Patient Reported Outcomes into an Electronic Health Record

Abstract

Background. Patient-reported outcome measures (PROs) have become an essential component of quality measurement, quality improvement, and capturing the voice of the patient in both research and clinical care. In 2004, the National Institutes of Health endorsed the importance of PROs by initiating the Patient-Reported Outcomes Measurement Information System (PROMIS), which leverages computer-adaptive tests (CATs) to reduce patient burden while maintaining measurement precision. Historically, PROMIS CATs have been used in a large number of research studies outside of the electronic health record (EHR), but growing demand for clinical use of PROs requires creative IT solutions for integration into the EHR. Methods. This paper describes the introduction of PROMIS CATs into the Epic Systems EHR at a large academic medical center using a tight integration; we describe the process of creating a secure, automatic connection between the application programming interface (API) which scores and selects CAT items and Epic. The overarching strategy was to make CATs appear indistinguishable from conventional measures to clinical users, patients, and the EHR software itself. We implemented CATs in Epic without compromising patient data security by creating custom middleware software within the organization’s existing middleware framework. This software communicated between the Assessment Center API for item selection and scoring and Epic for item presentation and results. The middleware software seamlessly administered CATs alongside fixed-length, conventional PROs while maintaining the display characteristics and functions of other Epic measures, including automatic display of PROMIS scores in the patient’s chart. Pilot implementation revealed differing workflows for clinicians using the software. Results. The middleware software was adopted in 27 clinics across the hospital system. In the first two year of implementation, 793 providers collected 70,446 PROs from patients using this system. The project provided valuable lessons in the areas of interdisciplinary teamwork and clinical implementation.