Implementing howRU

Patients are usually very happy to complete howRU, provided that they are asked, because it is easy and only takes a few seconds.

The process of completing any patient-reported outcome measure, such as howRU, involves several steps:

• Administer the questionnaire.
  • Ask the respondent to compete the questionnaire. This can be done by a person directly, by letter, telephone call or computer screen.
  • Provide the questionnaire to respondent; both have to be at the same place at the same time.
  • Complete the questionnaire; the respondent has to have enough time to complete the job and the right equipment to hand (e.g. a pen).
• Return the questionnaire for analysis.
  • Send or submit the questionnaire to a central repository.
  • Check the form for completeness and validity.
  • Enter into a database data-base for analysis.
  • Link entry with previous records or data from other sources.
• Presentation of results and feedback.
  • Calculate and analyse results.
  • Present results, for example as charts.
  • Deliver results to interested parties.

The choice of method used to collect howRU data depends on the aims and objectives of the project or study.  The wide variety of healthcare settings and processes requires a choice of modes of assessment, trigger events and locations.   

Modes of assessment may be paper, verbal or electronic.  The design is suitable for web-browsers, touch-screen kiosks and portable devices such as smart-phones and tablets.

Identification of trigger events is key to success.  A trigger event is the action that causes something else to happen, typically to ask the patient to complete the questionnaire.

Change Management

The introduction of howRU requires change management, which Kotter[1] describes as having eight steps:

1. Establish a sense of urgency that change is needed.
2. Form a powerful guiding coalition with position power, expertise, credibility and leadership.
3. Create a vision and strategy which is imaginable, desirable, feasible, focused, flexible and communicable.
4. Communicate the change vision simply, using metaphor analogy and example, repeated over again in multiple forums; lead by example, address apparent inconsistencies, listen and be listened to.
5. Empower employees to change structures and systems to effect change.
6. Generate short-term wins which are visible, unambiguous and clearly related to the change effort.
7. Consolidate gains, eliminate interdependencies and produce more change.
8. Anchor new approaches in the culture.

Senior management backing is crucial, because changes are likely to be needed in process, work flow and information systems to ensure that howRU assessments are done regularly and information flows back to inform clinical decisions.

Technical support may also be required to set up and maintain the system (paper or electronic), to educate staff and provide help to individual patients. When first introduced, there should be someone on hand to answer questions and help with problems.

howRU takes only a few seconds to complete, using either paper or electronic data collection.  Ideally, data collection is an integral part of another routine task that patients need to perform, such as booking appointments, checking in on arrival at clinic, ordering or collecting repeat medication.

Clinical acceptability depends on face validity (does it look right?), published evidence (I am not being deceived) and value to themselves (this is worth the time and trouble to do).  A cumulative record, tracking each patient’s history, can be invaluable if the clinician does not know the patient well. It saves time piecing together a verbal history, helps identify problems such as a mental health or social services needs and provides a common language for patients and clinicians to communicate.

Respondent Burden

Other barriers to use of any HRQoL measure, such as howRU, include the respondent burden and the need for staff to be trained to understand the results. 

Respondent burden is a function of brevity – how long it takes to complete the questionnaire; readability – how easy it is for people to understand the questionnaire in a common way, and convenience – whether the patient obtains direct benefit from the process.

Brevity leads to higher participation rates, reduced respondent resistance and better quality data, with less missing data and satisficing responses (where a respondent answers questions in an unthinking way).

Readability is self-evidently important, yet researchers have found that most commonly used instruments have many items with readability levels below the threshold recommended for documents to be used by vulnerable people of a readability grade score of 5.0 or less and a reading ease score of over 80 (Paz et al 2009)    The howRU form has a grade score of 1.8 and ease score of 89.  The acceptability of howRU is indicated by every respondent completing all parts of howRU (100% completion) in a telephone survey of almost 3,000 subjects with long-term conditions. 

Reliability and Callibration

All scientific measurement is callibrated against standards – for example in hospital laboratories, analytic instruments are calibrated and checked against carefully produced controls, which in turn have been tested against other standards.  Only in this way can we rely on the comparability of measurements made in different places. In health surveys, the respondent is the sensor and needs to be calibrated.  

We know of only two ways to do such calibration.  One option is to implement a formal training course, but such training is not practical for patient-reported measures in routine clinical use.  The only alternative is to use terms that have commonly understood meanings as taught in primary school.  For example most people in England can easily distinguish between pink and purple, because this is taught at school, while many do not know the difference between magenta (dark red) and cyan (light blue).

Complete reliability cannot be achieved and any rating must be associated with an error component.  Reliability is compounded when two ratings are compared, since the errors associated with both ratings must be considered, but the difference being examined may be quite small.  Yet more errors are introduced when valuations are attributed to each rating because the standard errors achieved by the types of scaling techniques used in health indicators can be rather high. 

Operating Conditions

Systems must be designed to operate under the worst conditions likely to be met in practice.  It is no good to design a system that operates successfully under ideal conditions but suffers breakdowns when put under stress.  At times, conditions in health services can cause staff to be stretched to breaking point, and in these circumstances additional tasks will simply not be completed unless everything is done to minimise the burden.