Electronic Questionnaire Effectively Integrates Patient-Reported Outcomes in Clinical Care


Electronic patient-reported outcome (ePRO) questionnaires may allow rheumatologists to better understand the patient's experience and monitor improvements over time.

The novel Audit4 electronic patient-reported outcome (ePRO) system proved to be a valuable tool for incorporating PROs into a clinical care setting and helped to provide a better understanding of disease burden and the impact of interventions in a real-world setting, according to a study published in Frontiers in Digital Health.1

Electronic Questionnaire Effectively Integrates Patient-Reported Outcomes in Clinical Care

Kathleen Tymms, MD

“When incorporated into routine care, PROs can help the clinician to better understand the patient experience, enhance communication and encourage shared decision making, which can empower the patient in the management of their own condition,” Kathleen Tymms, MD, clinical rheumatologist at Canberra Rheumatology in Australia, and colleagues, wrote. “However, the realities of time pressures during routine clinical care can significantly hamper recording of PROs in a regular or systematic fashion.”

Validated questionnaires were sent from the electronic medical record (EMR) (Audit4) of patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), lupus, ankylosing spondylitis (AS), or giant cell arteritis (GCA) to either the patient’s email address or completed via smart device in the clinic waiting room. These questionnaires were then encrypted and sent back to the patient’s Audit4 EMR. Clinical data was collected across all sites and analyzed. The delivery system was developed by Software for Specialists (S4S) in conjunction with OPAL Rheumatology.

A total of 221,352 questionnaires, including the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F), HealthCare Resource Utilization (HCRU), and/or Patient Health Questionnaire-2 (PHQ-2) were sent between April 2016 and December 2020 from 39 contributing clinics. The PHQ-2 asks about the frequency of depressed mood and anhedonia in the last 2 weeks and the HCRU asks about medical events and treatments from the last 3 months. The questionnaires were delivered by email (85%) and in-practice (15%).

Most (85%) patients completed 1 or more questionnaires and 73% of all questionnaires were completed. Older patients (over 80 years of age) were slightly more likely to complete all questionnaires (≥50%) compared with patients under 70 years. Female patients were more likely to participate in the questionnaires when compared with men (87% vs 81%, respectively). Most patients, aged 80 years and younger, were more likely to complete all questionnaires if they were sent via email. However, patients 80 years and older were more likely to complete them in a clinical practice setting.

The rheumatologist was not able to decide to use ePRO technology, as well as which patients received the questionnaires, which may have resulted in selection bias. Additionally, self-reported questionnaires run the risk of bias and misinterpretation, which may have hindered the validity of the findings. Future studies should evaluate fatigue levels, healthcare resource utilization, and mood disturbance in this patient population.

“The data presented here reflects the real-world use of ePROs in routine clinical practice,” Tymms concluded. “Importantly, this high completion rate was also sustained over time and many patients had completed multiple ePRO questionnaires. This is important as it allows the treating rheumatologist to track their patient's PRO measures longitudinally and monitor improvement.”


  1. Tymms K, O'Sullivan C, Smith T, et al. A novel electronic patient-reported outcome delivery system to implement health-related quality of life measures in routine clinical care: An analysis of 5 years of experience. Front Digit Health. 2023;4:1074931. Published 2023 Jan 9. doi:10.3389/fdgth.2022.1074931
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