Table 4 –

Suggested best practices for PROM collection in colorectal surgery clinics using Snyder and Wu’s questions as a I framework.^15,37

Question	Suggested best practice in colorectal surgery
Planning phase
1. What strategy will be used for integrating PROs in EHRs?	Whenever possible, PROMs and PROs should be fully integrated into the EHR. This allows for PROM collection through both the patient portal and EHR. Moreover, it facilitates real-time review by surgeons and the ability to integrate PROMs into clinical care
2. How will the PRO-EHR system be governed?	The specifics of who in the organization has control of routine PROM collection and integration with the EHR is a matter that will often be decided locally. We pursued a hybrid model of PRO-EHR system governance, where a committee comprising clinicians, nurse practitioners, nurses, and researchers with experience in PROMs selected desired PROMs and then oversaw implementation in collaboration with an institutional project manager. Regardless of operational control, surgeons should ensure that the necessary PROMs to track global patient health, as well as health in common colorectal diseases, are recorded in their PRO-EHR system
3. What are the ethical and legal issues?	Patient privacy in PROM collection is paramount. Collection of PROMs should be done in the EHR and through an HIPPA-compliant patient portal. We informed patients about their PROM surveys, going into detail when asked, but did not specifically provide opt-out information. We believe this approach improved our response rate
4. How can PRO data from multiple EHRs be pooled?	Our institution functions under a single EHR. Therefore, we do not have best practice recommendations for this question
Selection phase
5. Which populations and patients are most suitable for the collection and use of PRO data, and how can EHRs support the identification of suitable patients?	The vast majority of patients in the colorectal surgery clinic are suitable for the collection and use of PRO data. The EHR should be lever-aged to automatically identify postoperative and disease status, administering or withholding surgery-specific or disease-specific PROMs accordingly There are important limitations to PROM collection surrounding spoken language, disability, cognitive decline, and unfamiliarity with electronics that are present in the colorectal surgery clinic population. Such factors may result in inequitable PROM completion rates. Efforts, such as choosing PROMs available in multiple languages, should be made to reduce these disparities
6. Which outcomes are important to measure for a given population?	A mixture of generic and disease-specific PROMs should be collected from patients in the colorectal surgery clinic. We recommend collecting, at a minimum the PROMIS Global-10, QoR-9, EORTC-QLQ-CR29, SIBDQ, and DV-QOL instruments (see Discussion). If a particular clinic focuses on a less common colorectal pathology, then that clinic should consider collecting a validated, disease-specific PROM for patients with that condition. It is important to standardize the selection of PROMs across colorectal surgery clinics to improve the comparability of research and clinical performance
7. How should candidate PRO measures be evaluated?	All PROMs collected should be validated and commonly used in the colorectal surgery literature
Engagement phase
8. How, where, and with what frequency will PROs be administered?	We strongly recommend that PROMs be routinely administered to each colorectal surgery clinic patient before every appointment. This provides several advantages, including the ability to track disease states and severities across time, perform high-powered prospective and retrospective outcomes research, and monitor the quality of care that is provided. The specific PROMs collected at each appointment should vary depending on the patient’s disease state and postoperative status
9. How will PRO data be displayed and accessed in the EHR?	PRO data should be accessed on a user-friendly dashboard within the EHR and end-user testing should be performed before operationalizing the dashboard. Overall scores should be readily visualized, and individual responses to questions should be available by clicking on the PROM. Responses should graphically display the directionality and meaning of PRO scores for easy understanding of change over time. If possible, dot phrases or other code should be available that readily pulls PRO data into the provider’s note for easy access
10. How will PRO data be acted upon?	Routinely collected PRO data in colorectal surgery clinics can be utilized for outcomes research, quality improvement, and clinical care. Further research is critical to enhance our understanding of how to apply PROMs to improve clinical practice
11. How can users be trained and engaged?	PROMs can be collected electronically on tablets following arrival at the colorectal surgery clinic. The receptionist should be able to load the PROM(s) on a tablet with minimal disruption to their workflow. If the clinic has a patient portal linked to their EHR, such as MyChart or MyHealth, patients should have the opportunity to complete their PROMs through the portal in the days leading up to their appointment

PRO = patient-reported outcome; HIPAA = Health Insurance Portability and Accountability Act.