Brigham & Women's Hospital: Using Patient Reported Outcomes to Improve Breast Cancer Care Custom Case Solution & Analysis

Evidence Brief: Patient Reported Outcomes at Brigham and Womens Hospital

1. Financial Metrics

• Total investment in Epic electronic health record integration remains an undisclosed capital expenditure, but represents the primary infrastructure cost for Patient Reported Outcome (PRO) deployment.
• Value based care transition targets a reduction in post operative complications, which currently drive significant readmission costs.
• The cost of hardware includes the procurement of tablets for waiting room data entry across the oncology department.
• Reimbursement models are shifting toward quality metrics, where PRO data serves as a potential proxy for hospital performance ratings and incentive payments.

2. Operational Facts

• The BREAST-Q tool is the primary instrument used to measure satisfaction and quality of life after breast surgery.
• Data collection occurs via tablets in the waiting room or through the patient portal before clinical visits.
• The Patient Reported Outcomes Measurement Information System (PROMIS) provides standardized scores for physical, mental, and social health.
• Clinicians access PRO data through a specific dashboard within the Epic EHR system.
• BWH performs thousands of breast cancer procedures annually, creating a high volume data environment.

3. Stakeholder Positions

• Dr. Monica Bertagnolli: Advocates for the integration of clinical research and clinical care through standardized data.
• Dr. Andrea Pusic: Expert in PRO development; emphasizes that the data must be actionable for the surgeon to be valuable.
• Dr. Tari King: Focuses on the feasibility of implementation within the high pressure surgical workflow.
• Patients: Express high initial willingness to provide data but show declining participation during long term survivorship phases.
• Nursing and Administrative Staff: Responsible for the physical distribution and sanitization of tablets in clinics.

4. Information Gaps

• The specific dollar value of cost savings per patient attributed to PRO usage is not quantified in the case.
• The exact percentage of clinicians who actively change treatment plans based on PRO scores is missing.
• Long term retention rates for patient portal data entry after the five year mark are not provided.
• Comparative data against peer institutions using identical PRO tools is absent.

Strategic Analysis: Moving from Collection to Clinical Action

1. Core Strategic Question

• How can Brigham and Womens Hospital transform PRO data from a passive research metric into an active clinical tool that improves patient outcomes and justifies the cost of value based care?
• How can the hospital ensure clinician adoption without increasing the administrative burden in an already compressed 15 minute consultation window?

2. Structural Analysis

Applying the Value Chain lens to BWH operations reveals that PRO data currently sits in the support activity of Technology Development rather than the primary activity of Service Delivery. For PROs to create competitive advantage, they must move into the primary care delivery path. The bargaining power of buyers (insurers) is increasing, demanding evidence of quality beyond simple survival rates. PROs provide this evidence, but only if the data is longitudinal and standardized.

3. Strategic Options

Option 1: Full Clinical Integration. Hardwire PRO scores into the standard of care. Surgeons must review the BREAST-Q dashboard before entering the exam room.
Rationale: Ensures the data impacts the patient experience immediately.
Trade-offs: Increases clinician burnout risk and requires significant workflow redesign.
Resources: Intensive training and EHR optimization.

Option 2: Research and Benchmarking Focus. Use the data primarily for long term outcomes research and institutional marketing.
Rationale: Minimizes daily clinical friction while building a massive longitudinal dataset.
Trade-offs: Fails to improve individual patient care in real time; risks patient fatigue if they see no direct benefit.
Resources: Data scientists and research coordinators.

Option 3: Patient Directed Care. Provide the PRO scores directly to patients via the portal to facilitate self management and shared decision making.
Rationale: Empowers the patient and reduces the burden on the clinician to interpret every data point.
Trade-offs: Requires high patient health literacy and may cause unnecessary anxiety over minor score fluctuations.
Resources: Patient education materials and portal development.

4. Preliminary Recommendation

BWH should pursue Option 1. In a value based environment, the hospital cannot afford to treat PROs as a side project. The surgical outcome is no longer defined only by the absence of disease but by the restoration of function and satisfaction. Integrating these metrics into the daily workflow is the only way to ensure the investment in Epic and BREAST-Q yields a clinical return. This requires a shift in surgical culture where the PRO score is treated with the same importance as a pathology report.

Implementation Roadmap: Clinical Integration and Workflow Optimization

1. Critical Path

• Month 1: Redesign Epic dashboard to highlight significant changes in PRO scores (red flags) rather than showing raw data.
• Month 2: Pilot a pre-visit huddle where nurses brief surgeons on the PRO scores of the upcoming patient.
• Month 3: Automate patient portal triggers to send surveys three days before scheduled appointments to increase completion rates.
• Month 6: Conduct a departmental review to correlate PRO scores with readmission rates to prove clinical utility.

2. Key Constraints

• Clinician Time: Surgeons operate in a high volume environment where every extra minute spent on a dashboard is a minute lost with a patient.
• Data Accuracy: Patients may underreport symptoms to please their surgeon or overreport to gain more attention.
• Technical Friction: The current EHR interface requires too many clicks to reach the PRO visualization.

3. Risk-Adjusted Implementation Strategy

To mitigate clinician resistance, BWH must implement a tiered alert system. Instead of requiring a review of all 20+ PROMIS domains, the system should only alert the surgeon if a score deviates by more than one standard deviation from the baseline or peer average. This reduces the cognitive load. For patient participation, the hospital should transition away from tablets in the waiting room toward a mobile-first portal strategy, as this allows patients to reflect in a less stressful environment. If participation drops below 60 percent, the hospital must trigger a secondary administrative follow up during the check-in process.

Executive Review and BLUF

1. BLUF

Brigham and Womens Hospital must move PROs from a research initiative to a core clinical requirement. The strategic value of PROs lies in their ability to reduce post operative complications and improve patient satisfaction scores, which are increasingly tied to reimbursement. The current implementation faces a critical bottleneck: clinician adoption. To succeed, the hospital must simplify the data presentation within Epic to provide actionable alerts rather than raw data. Success will be defined by the ability to use BREAST-Q scores to identify and intervene in patient distress before it requires costly readmission or revision surgery. The window to lead in this space is closing as peer academic centers adopt similar tools. Execution must focus on workflow integration and data utility for the surgeon.

2. Dangerous Assumption

The analysis assumes that surgeons will find PRO data inherently valuable enough to change their clinical behavior. In reality, many surgeons prioritize objective clinical markers over subjective patient reports, and without a clear mandate or financial incentive, the PRO dashboard may remain unread.

3. Unaddressed Risks

4. Unconsidered Alternative

The team failed to consider a peer-to-peer benchmarking strategy. By showing surgeons how their patients recovery scores compare to departmental averages, BWH could use professional competition to drive both data collection and quality improvement. This social proof mechanism often moves the needle faster than administrative mandates in academic medicine.

5. Verdict

APPROVED FOR LEADERSHIP REVIEW