A PROMISing Future for Patient Care

When a patient walks in the door at Shriners Hospitals for Children — Portland, it’s very common to see a staff member from clinic hand them an iPad and ask them to complete a short survey that appears on the screen. Developed by the National Institutes of Health, the survey, aptly called PROMIS, stands for Patient-Reported Outcomes Measurement Information System, and it is part of a system-wide quality improvement project designed to show how our treatments produce positive clinical outcomes and quality of life improvement, from the voices of our own patients.

The survey takes only three to five minutes to complete, and it is unique because the patient answers the questions themselves, rather than their parent or guardian. The program was launched at Shriners Hospitals for Children — Portland in 2017, and since then more than 4,000 patients have used the iPad to share information with their physicians. That number continues to grow.

Once the patient touches the “submit” button, the iPad automatically submits the PROMIS scores into their electronic medical record, allowing their physician to view their answers almost instantaneously. The patient answers questions concerning pain interference, mobility, upper extremity function and social health. The physician sees these scores before entering the patient’s room, potentially influencing the care and treatment provided in their appointment.

“The intent of PROMIS is not just to gather patient data, but to let the patient know that we truly value their voice during their course of treatment. If we are going to be making quality-driven changes on how we practice, the patient’s voice should be at the center of that change,” said Carly Woodmark, MS, clinical quality outcomes coordinator at the Portland Shriners Hospital. Carly implemented the PROMIS program at the hospital, and she continues to collaborate with the staff to utilize the data gathered to improve care. “By making these surveys available, patients are invited to be more involved in their care experience. When there is greater physician-patient collaboration, patients experience better outcomes and choose less costly yet effective interventions, which is the foundation of value-based health care.”

While physicians react to individual patient’s PROMIS results in real time, Carly analyzes the data as a whole to look for trends and identify gaps where the Portland Shriners Hospital staff can add value and improve the results of care that patients receive. In 2019, Carly collaborated with Daniel Bouton, M.D., to assess the data gathered in PROMIS surveys, and together they discovered a clear correlation between patients’ psychosocial health and their physical health. While similar findings have been previously supported in various adult patient populations, few published studies show the same correlations in pediatrics.

“In the field of specialty pediatric orthopaedics, we tend to be very focused on what’s in front of us. If there’s a broken bone, we fix it. If a child has scoliosis, we straighten their spine,” said Dr. Bouton. “It can be difficult to spot mental health needs in kids unless you’re looking for it. With these findings, I hope we can develop a standardized way to screen kids for mental health needs.”

Dr. Bouton presented the results of this robust data analysis targeting quality improvement, PROMISing: Process Improvement in Psychosocial Health, at the International Consortium for Health Outcomes Measurement annual conference in 2019. The results were also accepted and presented by Carly Woodmark at the American College of Surgeons 2020 Quality and Safety Conference.

Shriners Hospitals for Children — Portland is taking a big step in bridging the gap identified by the results of this psychosocial health initiative. In addition to adding psychosocial screening questions as part of the checklist during the surgical waitlist appointment, hiring a child psychologist is underway in order to provide consistent care for patients in need of mental health support, and to eliminate the current referral process for at-risk patients to an outside mental health provider. Nursing staff members have also expanded their efforts by receiving training in evidence-based trauma informed principles. This training will help them to better care for patients with known childhood trauma and to provide better care at every touch point of the patient and family experience.

“Unfortunately, there’s still such a stigma around mental health, especially in the assumptions that mental health doesn’t affect physical health outcomes. According to our results, it’s undeniable,” said Carly. “At Shriners Hospitals for Children, we want to treat the whole patient in a comprehensive wraparound care model, and mental health plays a significant role in that.”