Which is better? Paper or Tablet for Measuring PROs?


Patients often view positive outcomes differently from doctors. A new study questions which tool is better for measuring patient reported outcomes: paper or tablet.

Patient-reported outcomes have become increasingly important in assessing the quality and effectiveness of care and in deciding on treatment approaches. Patients often view positive outcomes differently from their doctors.

At the American College of Rheumatology annual meeting in November, at least 15 studies were devoted to this subject. In rheumatology, PROMIS -the Patient-Reported Outcomes Measurement Information System - is extensively used and is available in multiple formats. A new study published in November issue of the American Journal of Orthopedics, explores which format is better, paper or tablet?

Apparently, there is little difference between the two, but the tablet form seems to have more advantages over paper, writes Kalpit N. Shah, M.D., of Brown University, and colleagues. Ease of use, adaptability and patient preference were cited as preferences for tablet surveys.

Dr. Shah’s study showed that digital tablet data collection was non-inferior to paper data collection with time to completion and computer scores not being significantly different as well. However, patients preferred to use tablets in future surveys.

This was a prospective, randomized study looking at utilization of digital tablets versus paper forms for collecting patient reported outcomes. The authors postulate that advantages to using tablets for surveys include: simultaneous input of data into databases, improved accuracy, high completion rates and ease of long term storage.

Patients were recruited at orthopedic clinics and ultimately 483 orthopedic patients were included in the study:  56 years average age, 51% female, 50% owned tablets, 70% owned smartphones. 258 were randomly assigned tablets and 225 assigned paper surveys. Patients were asked to complete the Oswestry Disability Index (ODI) for low-back pain, the Neck Disability Index (NDI) for neck pain, the Hip Disability and Osteoarthritis Outcomes Score (HOOS) for hip pain, the Knee Injury and Osteoarthritis Outcomes Score (KOOS) for knee pain, or the QuickDASH survey for upper extremity complaints (subspecialty-specific).

Basic demographics, comfort with computers, quality of life and disease specific questions were presented to subjects with the primary outcome being survey completion rate. Secondary outcomes included time to completion, questions left unanswered, patient satisfaction with survey length, ease of completion, comprehension, and finally, 41.4% of patients in the paper survey group preferred tablet as compared to 19.7% in the tablet group who asked for paper.

The overall completion rate was 84.4% with no significant difference in completion between the tablet and paper groups or the time it took to complete the survey. Prior studies showed that completion rates with tablets were higher than with paper and that digital data may have been more valid than those collected by paper survey. Time to completion and overall satisfaction were no different between groups.

In terms of specific measures, EQ-5D quality of life scores were higher in the paper group than the tablet group (p=0.041), while pain visual analog scores were higher for the paper group than the tablet group (p<0.001) and finally neck disability index (NDI) scores were higher for the tablet group than paper group (p=0.33). Other measures were not significantly different.

The authors point out that unequal recruitment between different subspecialties and lack of each subject being able to compare tablet versus paper may have limited the study. However, randomization and large sample size should mitigate these limitations.

Key Points

  • Collecting patient-reported outcome data with digital tablets is not inferior to paper collection with regards to overall completion rates.
  • Similar time is needed to complete digital surveys when compared to paper ones.
  • While quality of life scores were statistically higher in the paper survey group, the difference was not clinically significant.
  • Over 40% of paper survey takers preferred using a tablet in the future.
  • The benefits of fast and accurate data transfer and non-inferiority point to digital survey collection as the superior modality.



Kalpit N. Shah  MD; Martin R. Hofmann  MD, et. al. "Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study," American Journal of Orthopedics. November 2016. 45(7):E451-E457

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