Technical Primer

ePRO integration approaches

There are many approaches to using technology for ePRO data collection and application, and there is often no “one size fits all” solution (Hsiao et al, 2019; Segal et al, 2013; Snyder et al, 2017). Each health system will need to select the ePRO integration approach that best aligns with their goals, resources, and existing environment, and that approach may evolve over time. The goal of this toolkit is to provide information that can guide healthcare organizations in selecting the best strategy for their system. However, at a high level, there are three fundamental approaches that can be considered: EHR only, third party only, and a hybrid of EHR and third party tools (see Figure 1F).

Figure 1F: Fundamental approaches to ePRO technical integration
Figure showing a scale of integration, with EHR Only being more integrated, Third Party Only being less integrated, and Hybrid in between.
  • In the EHR only model, the EHR is the only tool used to facilitate ePRO data collection and reporting. This approach may allow for a more seamless experience for users, but EHR tools may have limitations in functionality or customizability.
  • In the third party only approach, ePRO data collection and reporting occurs through an app or web platform that is external to the EHR. Third party apps may be more nimble to launch and customize; however, collecting data outside the EHR may potentially present barriers to uptake and workflow, particularly for ePRO reporting.
  • In the hybrid approach, both the EHR and a third-party tool are used with some degree of integration. Full integration will allow data to flow back and forth between the tools, whereas for partial integration, data may only flow one way or may be limited in scope. This approach can capitalize on the flexibility of third-party tools while still maintaining a footprint in the EHR workflow and documentation; however, it may raise additional data security or interoperability challenges.

The capabilities of ePRO technologies vary widely, and certain technologies may better meet the needs of different care settings, users, or existing technology environments.

For example, the use of third-party platforms may allow each local practice within a healthcare organization to easily tailor the ePRO content and cadence to their local workflows. For one healthcare organization, this may be seen as a benefit, as it minimizes the burden on the centralized IT resources needed to support, adjust, and maintain ePRO tools. To another organization, however, this approach may undermine efforts to standardize and maximize use of the native EHR.

When determining which approach to use, one of the most important considerations is how ePRO data will need to flow between platforms in order to support ePRO data review at the point of care and by other stakeholders. Figure 1G gives an example of data flow considerations for the collection, storage, and display of ePRO data when using a hybrid approach.

Figure 1G: Example of data flow processes for hybrid approach to ePRO integration
Figure showing how data flows to and from a patient, through an Electronic Health Record, Third Party Platform, Electronic Data Warehouse, and Population Health Reporting Tools.

In response to the growth of ePRO tools, agencies such as PCORI, Health Level 7 International (HL7), the Office of the National Coordinator (ONC), and AHRQ have partnered on several initiatives to facilitate the implementation of ePROs in clinical workflow.

The PCORI’s Users’ Guide to Incorporating Patient-Reported Outcomes into Electronic Health Records (Snyder et al, 2017) provides thoughtful framing questions to assist healthcare settings in assessing potential ePRO platforms. The HL7 PRO FHIR Implementation Guide (FHIR Overview [HL7 FHIR] nd) provides direction and technical specifications for the capture and exchange of ePRO data using FHIR standards. As part of this effort, HL7 and ONC established preliminary structured data standards that allow the same ePRO variable to be captured and shared across multiple platforms (EHRs, apps, etc.). Please see Technical ePRO Guides in the Tools and Resources section for more information.

In comparison with those guides, our toolkit will focus on key considerations for how technology will impact the use of ePROs in practice, including:

  • the need for multiple data collection modalities
  • customization of ePRO content or functionality for ePRO reporting
  • alignment with clinical workflow
  • the preferred location for data storage and reporting tools (i.e., within the EHR, data warehouse, or external tool)
  • the healthcare organization’s available resources and approach to technology management

As healthcare organizations begin to understand their current capabilities and evaluate potential technology platforms of choice, it will be critical to first consider the needs of users (e.g., patients, care teams) and then select the technology that best aligns with the desired care delivery experience.