Value-based Healthcare: Patient-reported Outcomes in Clinical Decision Making

M easuring outcomes from the patient’s perspective is not a new concept. In 2010, the Harvard Business School economist Michael E. Porter PhD wrote: ‘‘Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge’’ [4]. Previously, outcome instruments consisted of factors the physician found important and were used primarily for research on a new technique or treatment method. The analysis was completed at the end of the episode-ofcare and the treatment was either deemed successful or not. These physician-derived instruments, however, are being replaced with validated, real-time patient-reported outcomes (PROs). Through the use of PRO measures (PROMs), the patient’s voice is being heard, quantified, and compared to normative data in a large variety of domains such as physical function, pain, depression, anxiety, and fatigue. The PROMIS (Patient Reported Outcome Measurement Information System) is the product of a USD 100 million NIH initiative aimed at developing valid, precise measurements of a patient’s physical, mental, and social health. The various tools in the PROMIS toolkit can help the patient quantify what (s)he is able to do and how (s)he is feeling [5]. The questions can be asked in a paper format or electronically. The real efficiency advantage is in using the computerassisted technology (CAT) and itemresponse theory. This format allows for the followup question to be selected based on the response to the prior question. In this fashion, an available databank of 121 questions can be used selectively, choosing only those questions that best apply, in order to assess a patient’s physical function in as few as four to seven questions. This saves time without compromising accuracy or validity. The scores can be imported into an electronic health record for real-time viewing and clinical decision-making (Fig. 1). It is only through the efficient, valid, and instantaneously A Note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the latest Value-based Healthcare column (formerly Orthopaedic Healthcare Worldwide). Value-based Healthcare explores strategies to enhance the value of musculoskeletal care by improving health outcomes and reducing the overall cost of care delivery. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The authors certify that they, or any members of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. J. F. Baumhauer MD, MPH Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Elmwood Avenue, Box 665, Rochester, NY 14642, USA e-mail: Judy_Baumhauer@URMC. Rochester.edu