As we strive to provide better care at lower cost, it’s critical that we have tools to help our doctors determine the most appropriate treatment for patients. The term “appropriateness” is often used to broadly describe this process and includes both surgical and non-surgical interventions such as tests or x-rays. For example, is it appropriate to order an MRI for a patient with a headache? How long should a patient pursue physical therapy before considering back surgery?
These are complicated questions and many factors weigh into these decisions ranging from evidence-based clinical guidelines, risk factors, and patients’ personal goals and preference. To make it harder, these decisions are not always clear-cut, especially when dealing with complex cases. When care involves a procedure, like a surgical operation or a diagnostic test (for example using an endoscope to look into your stomach), one tool we use is “PrOE,” which stands for ‘Procedure Order Entry’. PrOE helps support physicians and patients, making the decision-making process as transparent and straight-forward as possible.
PrOE is a decision support tool that pulls in information from the patient’s medical record and inputs it into a complex algorithm, based on clinical guidelines, to help determine the most appropriate treatment. Using hard data, PrOE helps to answers questions like is medication the best treatment option or is surgery a better route? By putting the PrOE assessment up front, before a patient undergoes treatment, the patient and provider can be assured they have the best information before making any decisions.
PrOE also provides patients with personalized risk scores – PrOE isn’t calculating the risk for any patient, it is calculating the risk of this patient. So patients are able to see their risk of bleeding and other complications based on their medical history. By receiving tailored risks specific to their health, they have a better sense of the possible risks associated with the procedure.
Because each patient is unique, there are always cases that defy even the best algorithms, and PrOE never forces an option. The special process occurring in these clinics is the combination of sophisticated technology with the personal attention and expertise of our world-class physicians and surgeons who make sure that each patient is set on the best course of treatment.
How PrOE is Configured
When doctors are taught how to treat different ailments, or review cases that have gone poorly, they turn to clinical guidelines compiled by hospitals, researchers, and medical societies (like the American Society of Cardiology or the Society of Thoracic Surgeons). These are the same guidelines used in the PrOE tool. It just goes a step further to integrate the information into a digital, standardized process that your doctor can use right in the office.
Similar to the guidelines, the risk scores are based on peer-reviewed validated statistical models that are commonly used across the country. PrOE has made these easily accessible by building them into the program and with a few clicks PrOE can generate complex risk scores. These scores are then imported into a personalized consent form that includes the patient’s own risk scores from the PrOE tool.
The PrOE Process
If you’re a patient, say you come in with a herniated disc and pain in your lower back. There are several paths of care that you and your doctor could decide on. You could treat the problem with pain medication; you could go to physical therapy; or you could have surgery. When it comes to some health issues there’s no one-answer-solves-all option. Depending on your specific medical history, one path might have better outcomes than another
If you’re already a patient in the Mass General Brigham system, a program using natural language processing searches your radiology reports, lab tests, and provider notes and automatically pulls in this information from your electronic health record. It’s simple and streamlined for both you and your doctor. But if you’re a new patient, or if some of the information that gets pulled over is inaccurate or irrelevant, your physician always reviews your data manually. Once the PrOE tool has run your information through the system, it provides a score and rating of green (which is an appropriate treatment), yellow (which may be appropriate depending on other factors), or red (which may be inappropriate).
In addition to treatment options, PrOE can also be used to assess the risk of outcomes and side effects, like the risk of bleeding or kidney failure. Instead of finding out that the general public has a 5% risk of kidney failure, your physician can say you with your unique characteristics have a 3% chance of kidney failure, which is better than the general population or a 6% chance because you’re higher risk than the general population. This information is printed on a personalized consent for you. With a more informed consent process, you and your doctor can have better conversation about your choices.
Your goals and preferences are also important in determining among the options. If you have a complex medical history, your unique characteristics might be so rare it is not reflected in the clinical guidelines programmed or maybe your daughter is getting married in five months and you want to be able to participate in the ceremony. At the end, you and your physician always have the final say over what is most appropriate for you. With a combination of technology, expertise, and personal attention, our goal is to make sure that we help you make the best care decision possible.
***Note: PrOE is a pilot program that is implemented across several different hospitals in the Partners network for common surgical procedures including coronary artery bypass graft, valve repair/replacement, diagnostic catheterization, percutaneous coronary intervention, lumbar spine procedures (laminectomy, discectomy, and fusion), cervical fusion, carotid artery stenting, carotid endarterectomy, vena cava filter placement, incisional hernia repair, prostate biopsy, gastric bypass, and others.