Internet Tool Uses Patient Feedback to Improve Army Pain Management

By Sandra Basu

Army Pain Management Program Director Col. Kevin Galloway

Army Pain Management Program Director Col. Kevin Galloway

WASHINGTON — A new Internet tool is a powerful weapon to combat pain, and the DoD is now launching it in a pilot location.

The Pain Assessment Screening Tool and Outcomes Registry (PASTOR) recently was rolled out to the warrior transition clinic at Walter Reed National Military Medical Center in Bethesda, MD.

The electronic pain data registry and clinical support tool allows for the collection of relevant information from patients about their pain prior to their medical appointment. Proponents of the system say it will not only improve treatment decisions, but also will facilitate population-based pain research in the future.

Calling it a “game changer for medicine,” Army Pain Management Program Director Col. Kevin Galloway told U.S. Medicine that the need for the tool was identified by the Army Pain Management Task Force, chartered by former Army Surgeon General Lt. Gen. Eric B. Schoomaker.

“The No. 1 concern was the lack of a very meaningful measurement for pain that was validated and meant the same to the patient and clinicians and our lack of fidelity on which things worked well with which type of patients when it came to treating their pain,” he said.

The 2010 Pain Management Task Force report called for the development of PASTOR and pointed out that “the lack of a DoD and VHA pain-data screening and outcomes repository causes difficulty in making responsible decisions on the myriad of possible treatment modalities.”

“This lack of pain data makes counseling patients on pain procedure efficacy a challenge,” the report stated. “It also presents barriers to greater patient involvement in decisions about care, makes longitudinal comparison of changes in pain difficult and may limit availability of optional pain management techniques and medications.”

How It Works

Using PASTOR, patients can electronically answer pain-related questions from home prior to medical appointments. A summary report based on the patient’s responses is then provided to the clinician and helps guide the conversation between the provider and patient.

Galloway provided this example of how the system could work: If a patient is seeking an increase in pain medications, the clinician might see from the report that, when pain medication dosages have been increased in the past, the patient’s activity level decreased and depression risk increased.

“When you sit down with your provider with that two- or three-page report, it is a very action-oriented discussion based on statistically significant data,” he said.

Eventually, when more sites are using the tool, PASTOR will collect standardized pain-related data. That will make population-based pain research possible and further aid clinical decision-making.

“You go to see a cancer doctor and he can pull up statistics and databases and registries that are very mature with data on thousands of patients. And when you make decisions on your cancer care they will tell you, ‘Based on the data, if we do X, you have an x-percent or y-percent chance of success of going to remission,’” Galloway pointed out. “We don’t make all decisions like that in medicine, but I think we’ll come closer to that with pain over time as we accumulate more data on what seems to work in what situations with different types of patients and what doesn’t.”

Many of the PASTOR measures were selected from the National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS). The NIH PROMIS website explains that “PROMIS questionnaires measure what patients are able to do and how they feel by asking questions.”

“A patient’s answers to a set of questions are calculated into scores that can be used by them and their doctor in improving communication, managing health conditions and designing treatment plans,” the website explains.

The program also employs computer adaptive testing technology, which significantly reduces patient response burden while increasing precision within any question domain. Most patients complete PASTOR questions in less than 20 minutes.

With Northwestern University serving as the PROMIS Statistical Coordinating Center, Karon Cook, PhD, of the Feinberg School of Medicine’s Department of Medical Social Sciences, is providing expertise on the PASTOR project. Cook told U.S. Medicine that PROMIS was born out of the NIH’s recognition of the value of the patient’s perspective and the need to standardize measurement of this perspective in health research.

Patient-reported outcomes (PROs) are symptoms and outcomes that impact quality of life for the patient such as fatigue, social function, anger, depression, physical function and anxiety.

“For many of these patient relevant outcomes, there is no external gold standard. For example, there is no laboratory test to tell a clinician what someone’s pain level is. Rather, this has to be reported by a patient,” Cook pointed out.

The lack of standardized PRO measures makes it difficult for scientists to compare results across studies, Cook explained. That prompted NIH to spend more than $110 million on the PROMIS initiative to develop a library of PRO measures that can be used across a variety of chronic conditions and tailored to the individual patient, she added.

That meant the measures did not have to be developed from scratch for military pain medicine, Galloway pointed out, adding, “We were very fortunate that in that process we discovered PROMIS.”

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