How Patient-Reported Outcomes Improve Orthopaedic Care with Judith Baumhauer, MD, MPH

“I’m fine” is one of the most expensive sentences in health care, because it can hide pain, lost function, fear, and stalled recovery. We talk with Dr. Judy Baumhauer, a national leader in orthopaedic surgery and outcomes measurement, about how patient-reported outcome measures (PROMs) give patients a real voice in their care and give clinicians a clearer signal about what’s working.

We get specific about PROMIS and why computer adaptive testing can measure physical function, pain interference, and even depression in just a few minutes, then trend those scores across an episode of care. Dr. Baumhauer explains how her team scaled PROMs from orthopaedics to a system-wide workflow, how results show up in the electronic health record, and why the numbers are most powerful when they spark a better conversation rather than replace one.

Then we zoom out to the future of value-based care in orthopaedics: CMS requirements, public reporting, bundled payments, and the risk of choosing the wrong instrument. We dig into why certain mandated surveys can blur pain and function, how comorbidities and ceiling effects can skew “improvement,” and why PROMIS crosswalks could help standardize reporting while lowering implementation costs.

If you care about patient-centered care, orthopaedic quality measurement, and where reimbursement is heading, subscribe, share this with a colleague, and leave a review with your take: should PROMIS become the default language for outcomes reporting?

Transcript

Welcome And Guest Introduction

SPEAKER_00 0:23

Welcome to the AOA Future in Orthopedic Surgery Podcast Series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation, and other areas. My name is Doug Blundy, host for this podcast series. Joining us today is Dr. Judy Baumhauer. Dr. Baumhauer serves as the Associate Chair of Academic Affairs and Profession in the division of foot and ankle surgery in the Department of Orthopedics at the University of Rochester. In addition to providing clinical care, she holds a position as a medical director of the Promise for the University of Rochester Health Care System and is a board of directors on the Accountable Health Partners ACO for the Rochester region. She received her bachelor's degree from Springfield College in Massachusetts, her Master's of Science and Biology from Middlebury College, and her medical degree from the University of Vermont College of Medicine. She completed orthopedic residency at the Medical Center Hospital of Vermont and a fellowship in foot and ankle surgery at the Medical College in Wisconsin. While working as an attending at the University of Rochester, she obtained an MPH degree from the University of Rochester Department of Community and Preventative Medicine. She's the past president of the American Board of Orthopedic Surgery, the American Orthopedic Foot and Ankle Society, and the Eastern Orthopedic Association. She currently sits on the board of directors of the Promise Health Organization. And also, Dr. Bombhauer was a lieutenant colonel in the U.S. Army Reserve. So, Dr. Baumhauer, welcome to the podcast series, ma'am.

SPEAKER_01 2:22

Thank you, Dr. Lundy. Really appreciate being asked.

Why Patient Reported Outcomes Matter

SPEAKER_00 2:25

Thank you, Judy. Great to see you again. And I look forward to talking with you about this. So, in full disclosure, I've got to know Judy through our time together on the American Board of Orthopedic Surgery. And my ABOS partner, Charlie Sulzman, and Judy had a very special relationship. They'd known each other for quite a while. They're both foot and ankle surgeons, and they are both intensely interested in patient-reported outcomes. And so we would love to talk about today the future of patient-reported outcomes in orthopedic surgery and where you see things are going. So, can you give us a quick overview of how did you ever get involved in patient-reported outcomes? Why are you so interested in this stuff?

SPEAKER_01 3:08

I think patient-reported outcomes are really the center of how the patient is feeling and functioning. And I'm all about that. I think we all are as orthopedic surgeons. We really just want what is best for the patient. And yet we would go into a clinic visit or something after surgery or before surgery, and we would ask the patients, you know, hey, how are you doing today? And they would say, I'm fine. Well, you are you able to, you know, get back to work. And they go, Oh no, I can't get back to work. And then you'd sort of go back and forth on these questions, trying to gauge where they were feeling and where they were functioning. And it seemed like there might have been a better mechanism for that. So recognizing the patient is the center of what we're trying to do, and recognizing that there's probably a more validated way of collecting questions. Patient-reported outcome measures came into being that seem to fill that gap.

Building A PROMs System In Clinic

SPEAKER_00 4:09

So, how do y'all use those at Rochester in terms of taking care of patients? How does that actually work?

SPEAKER_01 4:15

So we began in 2015 really investigating if we could collect patient-reported outcomes at site of service where we were seeing the patients. And in that time, believe it or not, it wasn't really commonly done. You just collected it really for research. You did it when you were interested in studies, and then you didn't collect it for big gaps of time. And then at the end of the episode that you were interested in, you'd collect it again and then look at pre and post and decide whether or not the patient did well. And we thought maybe if we look at it in continuity between initially, we did it at every patient visit, and then we did it at the points of time where change was going to happen, or we could think that change might be happening. And that's kind of how we moved it along. We started in orthopedics and at our institution at the University of Rochester. We had it humming literally within six weeks. We had it humming off of a custom platform that super smart people picked, and we used the promise instrument. And other departments said, hey, we want to collect that too. And so we started spreading it across the institution. So now we have a system-wide collection of patient-reported outcomes measures that include promise and a number of other instruments that the providers felt were important to assess on their patients to guide their treatment plans.

SPEAKER_00 5:49

So let's suppose I'm a patient with a chronic foot problem that you've operated. How would you use that in my clinical care if I was coming to see you at the University of Rochester?

SPEAKER_01 6:03

So I would use it to determine whether or not, first of all, originally the patient really collected it at uh when they checked in. They check in and they complete an assessment. And that assessment included physical function and pain and depression, because we felt that it was important to know how the patient was feeling and functioning. And it would pop up instantaneously in our electronic record on a graphic display. And because it was really easy to interpret on this graphic display, we could tell whether or not the person was improving, flatlined, or actually digressing. And based on that and what our prior treatments were, we could make some decisions of whether or not things were working or they weren't working. And it doesn't stop us really, Doug, from talking to the patient, hearing how they think they're doing. It's more of a kind of a validation of that we've understood their history correctly and that we can move along with whatever treatment plan might be the next one and share that with them.

SPEAKER_00 7:09

So I'm sure that you looked at a number of the patient report outcomes. Why did you pick Promise as your standard for everybody?

SPEAKER_01 7:17

Oh, you know, prior to, it wasn't like Promise was the only thing that we collected prior to 2015. It was the wild, wild west. I mean, everyone collected their own stuff. Matter of fact, we had a really great spine surgeon that was with us at a point in time. And he used a QR reader code to scan the results in and be able to interpret the results. So he was like almost a little bit of a training vehicle for us since we used QR reader codes to distribute the patient-reported outcomes to our patients, pull up the right ones. So we decided on promise because it was a$100 million effort by the NIH to collect a centralized, validated, psychometrically sound instrument that looked at symptoms. So it was really about symptoms. So we'll probably get to this, but what we're in the midst of now with the knees and hips guys are they're collecting their coos and koos junior, and yet, and they're going through all this trouble to collect it all. And now, if the bat guys come into play, are they gonna collect us westry? So now we have another instrument and another instrument and another instrument. Promise actually could transcend all of those symptom complexes and be a general health status measure that will allow us to only have to use one instrument and save costs and implementation issues.

SPEAKER_00 8:55

Yeah, I think aren't the joint surgeons mostly using the hoose and the coos because the federal government's requiring them to do this through the HARR for certain payments, right?

SPEAKER_01 9:07

Oh, yeah. Well, it's hoose and coos junior. So when you say, well, what does that matter? Just a shortened form. No, it's not. What it is is a combined function and pain score. So you can't really tease out whether or not the patient's functionally doing better, or their pain's getting a little bit better, but they're not functioning any better, or that their pain is significant, but they're functional, it's combined. It makes it really troublesome. So from a standpoint of promise, we have crosswalked the greater we, okay, not the little orthopedic surgeon, me, we, the smarter guys than me, um, have crosswalked promise physical function and pain with hoose and coos, which is the adult version rather than the junior. And that demonstrated that promise is actually a better instrument than whoos and coos.

When To Add Tests Beyond PROMIS

SPEAKER_00 10:07

That's crazy. I know that we had a talk today in Grand Rounds, and they were talking about the timed up and go test and other tests like that as well. Y'all use stuff like that. And what how do you feel that that responds or correlates with promise or other patient report outcome measures?

SPEAKER_01 10:24

So I think there are a lot of different tests that you can use to try and delineate your patient's symptoms or activities and things. What I could see promise being a duel for is it would allow you to assess how a patient's feeling and functioning through an episode of care. And say you had specific areas that you were interested in uh delving down. So uh you wanted to know if the person was at risk to fall. So you might use a timed up and go test to assess whether or not they need some additional training around falls risk. I would tell you though, promise physical function is a pretty good indicator of whether or not a patient has risk to fall. So there are always the way to drill down. And some of these other patient-reported outcomes measures will help you drill down. But perhaps you need to identify if you need to drill down, and that's where promise is going to shine. It's going to be an indicator of whether or not patients storm well through their episode of care. Or if things are going astray, then you can pull them out and perhaps drill down with something different that might influence how you might treat that person. I mean, promise can't diagnose infection, right? It can just tell you they're not functioning as well and they're having more pain. So you're going to need additional testing to determine why it is they're not feeling well or having more pain or not functioning as well. And I only use those two examples because we're orthopedic surgeons, but I got to tell you, my pulmonary guys are using shortness of breath, my GI guys are using GI distress, the urology guys are using social limitations because of urinary incontinence, people have social isolation. So there are actually over 300 symptom complexes with promise that can be assessed.

Depression Scores And What They Reveal

SPEAKER_00 12:24

So speaking of which, the psychometric ones seem to have a tremendous correlation with the physical promise scores. I think y'all have identified a significant correlation there. Can you enlighten us some on the information?

SPEAKER_01 12:40

I you might have to clarify that a little bit.

SPEAKER_00 12:42

Like the depression in the season and things like that, how that seems to almost parallel the physical function one. Am I right?

SPEAKER_01 12:47

Or I'm not sure that's always right. I'll give you a great example. I would say someone who is depressed may not function as well. So that's where your correlation is comes into play. But there are other things I'll be in clinic and I'll look at their values and I'll see that they're functioning really well, but they're really depressed. And it's a change from where I saw them before. And I'll just say to them, I like I said, it doesn't explain away, it's just a number. You need to have a conversation. So I'll say, hey, I noticed that you're kind of sad. And they'd say, Oh, my dad just died. Well, that relationship is now tighter, my relationship with that patient, because I asked them about how they're feeling. And I noticed that they're feeling differently. A lot of times you might see them looking sad, but people are great at hiding stuff. So it's a great tool. I want to tell you one other thing. Sometimes there's depression from an episode. So we did a study on ankle fractures. So they had trimal ankle fractures and we fixed them and we got their promise scores with that pain interference, depression, and physical function. And even though their physical function was improving and their pain was getting less, we noticed also their depression was getting less. And we realized that really it was the episode of injury that made them sad. So as soon as they started to improve, their depression started to improve. In the beginning, I would look at this and I'd say, oh, it's a baseline score. The person's depressed and they have these injuries because trauma happens, right?

unknown 14:28

Right.

SPEAKER_01 14:28

And I'd say, Well, I wonder if I'm supposed to engage them with a counselor or something. But really, it's that they broke their ankle that they're sad. And you need to give them a little time to go through that. We saw the same thing with ACL reconstructions. Patients were depressed because they had an injury. And it doesn't always require an antidepressant med or a counseling event. Sometimes you just need to follow the patient along to see how those trends are happening. And that's, I think, really important too. And that's why collecting patient-reported outcome measures through the episode of care is important.

SPEAKER_00 15:07

So y'all are collecting these on everybody that comes to the clinic?

SPEAKER_01 15:11

Yes.

SPEAKER_00 15:11

Wow. Tell me what kind of reaction are you getting much pushback or are people saying, why am I doing this?

SPEAKER_01 15:18

or I I wouldn't say that people are saying, Why am I doing this? Sometimes they aren't as engaged with it as me. And so they won't actually explain it to the patients what's going on. So it becomes like another point where they get their blood pressure and they never talk about it. And sometimes the patients say, Why are you getting my blood pressure? You never even tell me what it is. Same thing with patient-reported outcomes measures. So it's important to let the patients know how you're using that data or how it's guided you. And I often I have this whole spiel for patients. I say, although you're an excellent communicator, sometimes I have trouble understanding what people are trying to tell me. So I use this as a standardized tool to allow me to gauge really how you're feeling and functioning. And they appreciate that. So I go with it.

SPEAKER_00 16:13

That sounds very well correct.

SPEAKER_01 16:15

I also want to tell you, Doug, it only takes less than a minute per symptom. We call them domains. So per domain, so if I do physical function, pain, and depression, then it takes actually 2.3 minutes. So patients don't have a problem with the time that it takes. Because we use a computer adaptive technology and item response theory. So you only ask the most appropriate questions. You don't ask them questions that go back and forth. It's not a static measure.

SPEAKER_00 16:46

You're doing this on iPads or some formal.

SPEAKER_01 16:49

Now we do it in Epic. Now we roll out through. So at the beginning in 2015, when we had our own custom platform, we did that probably until just a couple of years ago. So maybe 2023 or 2024, we swapped into Epic when Epic caught up. Before that, Epic didn't have the capacity, and we didn't want to lose that.

CMS Reporting And Payment Pressure

SPEAKER_00 17:11

All right. So put your magician's head on. Where do you see these going in the future? Are they going to become more adapted? Are we going to start using them more? Will patients buy into it more? Will it affect payment? What do you what you just I know that nobody can guess this, but you're as deep in the weeds in this as anybody I know. What do you think? Where do you think this would go in 10 plus years?

SPEAKER_01 17:33

Our major change has been that CMS has now dictated that Hulus and Kuse Jr. will be collected, or there'll be penalties. And it's going to be publicly reported, not directly, but through a kind of a calculation that they'll demonstrate, they'll say, of the patients that were collected, of the 60% of the patients that were collected here, the knees and hip replacement patients, we're able to get back to a certain level of functioning. And that's going to drive us. And it's coming. Anyone who hides is in trouble. It's already with hips and knees. Spine is already in play. They're in this process called Teams, where the first 30 days are a bundled payment plan, and then there's risk. So it is coming down the line. They have shoulders, they have ankle replacements. It's hard to believe that ankle will be on the early phase of this, but it is. So they're going for the replacements in the high cost items first, and then they'll start to roll in other things. They, of course, they have other areas of uh medicine that also are at risk. Uh, so things that are outside of orthopedics. So our friends and partners are uh facing this as well.

SPEAKER_00 18:59

So if you were advising RFK Jr., the Secretary of Health and Human Services, on the way that patient report outcomes should be used, and you could just pick orthopedic surgery, you could pick medicine as a whole. How would you counsel him or whoever is secretary of HHS that in the best practice you believe that patient report outcomes should be used and what manner in the future to do what? How would you see that would benefit the healthcare of the country the most?

SPEAKER_01 19:32

Yeah, I will I feel that patient-reported outcomes or giving the voice of the I always call it the vote, right? Rochester was the vote for women. We initiated the vote for women. I always think the vote of the outcome of this is really with the patient. And patient reported outcomes measures a lot, it gives the vote back. I want to tell you though, if I were really advising someone, I would say that CMS picked the wrong instrument. They really should pick promise, although they have promise global as one of the requirements. That's a static short form. It doesn't help you as much as if we had used uh promise, the cat tool. And it would save healthcare systems a lot of money. They wouldn't have to adjust for every single one. People don't understand how to score all these different ones. They the languaging for it is difficult, the communication is difficult, patients don't understand it. It would be better to do some standardized work on that. And like I mentioned, promises crosswalked with a number of legacy instruments. So if you had a favorite legacy instrument like Oswestri for the Spine Guys or whatever it may be, more than likely promises crosswalk that and there's a crosswalk table. And therefore, if you collected Oswestri because you love that at your institution, then you can crosswalk it and report the promise. So I don't see that there's any downside in that. And I really think CMS should think about that.

SPEAKER_00 21:03

The federal government even owns promise, right? Well, they developed it, right?

SPEAKER_01 21:07

Yeah, yeah.

SPEAKER_00 21:09

So in the future, you see a much larger adaptation of these scores and the use within clinical care patients?

Comorbidities Ceiling Effects And Penalties

SPEAKER_01 21:18

Absolutely. You know, I I just wrote an article for JBJS in the perspectives because one of the things that people are struggling with, and this is getting a little bit into the weeds, but it's around comorbidities and all the other things that affect patient-reported outcomes. And how can you know that this one value that you're providing is valuable? Somebody who has really bad diabetes and other cardiovascular, and their initial score is very low because they have a knee arthritis. But and you score them and they fit into the realm of their pre operative. Score being eligible for knee replacement. And as a surgeon, you feel they're eligible. Even though they're impaired, they don't have much room for improvement because their other comorbidities are limiting their function. And then the reverse is true too, where somebody's functioning pretty darn well, but they fall outside of the score that that CMS may feel is adequate for a baseline score, or that they are functioning pretty well and they're almost a have a ceiling effect where they've they do get some improvement and they're happy they had it done, but they don't meet the threshold for CMS. So surgeons are getting penalized. Really, it's the hospital system that's getting penalized. So that I think is a major issue that people are wrestling with right now.

SPEAKER_00 22:51

So you see further development in the scores to try to uh figure out how to work around that or identify that variable.

SPEAKER_01 22:59

I think that people are trying to figure out where the sweet spot is. And we always say we're orthopedic surgeons, give us the rules and we'll win the game. But I would tell you that it's really is about the patient. We should always recognize that the patient should be uh front and center here. And if they're having a significant amount of discomfort, pain-wise or something, and yet their function doesn't improve very much, but their pain does, they may not meet that threshold because who's coos uh who's in coos junior is a collapsed for both. So we can't really tease out the pain and the function, we could just get a total score. So anyway, there's a lot of details in how CMS is running this that are potential foals. And unfortunately, people will throw the baby out with a bathwater. They'll say, Oh, see this, this is so wrong, and therefore we should never collect proms again. But that isn't what is right. We just didn't choose the right instrument. We chose poorly instead of choosing wisely.

SPEAKER_00 24:08

All right. So, as you know, AOA is all about development of leadership. And I have introduced these uh my current institution. We were not doing them well, and I kind of started that up, and then I also introduced them in the large practice I was in before I came up here. So how did you tell me, give us some of the leadership experience, leadership pearls that you deployed to make this a thing that your partners and that the folks at Rochester were bought in and then doing this? You said it it clicked on very quickly and people jumped into it, but it's something new, and people generally need leadership for that. What how did you lead that effort? What leadership was done in that? How did that whole thing turn about? Can you give us examples so folks trying to undertake this can maybe learn from those examples as they try to influence the adaptation of proms into their practice?

SPEAKER_01 25:05

Sure. Well, first of all, I would totally allow any person that's interested in patient reported outcomes to contact me. We published on how we implemented this and things like that. Number one is nothing is free. I realize that. And you have to have some buy-in from the institution. Now, because it's now tied to reimburs reimbursement to some extent and it's expanding, that's going to be a little easier because the CMS is going to do that job for you. But I would tell you that you still need the first string guys and gals to help you out and make sure that there's some support through IT and your Epic training team and things like that. If it's going through Epic, you can't reinvent the wheel. You have to make it fit into a system that's already been working for you. There, and there are ways to do that. There are also a lot of people that are already collecting this. Don't feel like you're the first one. Don't reinvent the wheel. There's also Epic teams that have done this. There's a for Promise, anyway, there is a website, healthmeasures.net, that can help you implement Promise or talk to you at all about other patient-reported outcomes that you might be interested in.

SPEAKER_00 26:26

Wow, this has been extremely helpful. So it has been an absolute pleasure talking with my friend, Dr. Judy Baumhauer, about the future of patient-reported outcomes in orthopedic surgery. So, Judy, thank you so much for being on the podcast, ma'am.

SPEAKER_01 26:40

Yeah, thank you, Doug. Thank you for your patient-centered approach. I know that you believe just like me that the patient's the number one in the equation here. So really important. Thank you.

SPEAKER_00 26:50

Yes, ma'am. Thank you. And y'all stay tuned for future episodes in this podcast channel series.