Both the DoD and VHA are actively adopting the Extensions for Community Health Outcomes (ECHO) telemedicine initiative developed at The University of New Mexico under the direction of Sanjeev Arora, MD. Unlike more-traditional applications of telemedicine technology that link specialist providers with patients separated by distance using video telecommunications, the ECHO project focuses this communication technology on building knowledge networks between specialists at medical centers and primary-care providers at rural or underserved locations. The intent of the project is “to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes of this treatment.”³

Arora, et al.⁴ demonstrated that rural primary-care providers, when part of the ECHO network, could manage complex hepatitis C patients diagnostically and therapeutically as successfully as specialists. The New Mexico team has successfully empowered primary-care providers in managing a variety of chronic health problems including management of chronic pain and headache,diabetes and cardiovascular disease, HIV/AIDS, rheumatology and others. Both the Army and Navy are in the process of establishing ECHO networks, modeled after The University of New Mexico project, throughout the DoD.

Pain Assessment Screening Tool and Outcomes Registry (PASTOR) and Patient Reported Outcomes Measurement Information System (PROMIS)

Early in the PMTF effort, it was recognized that a common problem for pain management in the United States was lack of data to support many current pain-management procedures and techniques. Additionally, it was noted that effective pain management required extensive inquiry into the many psychosocial aspects of the chronic pain condition. This information can be exceedingly difficult to obtain in the characteristically limited time allotted for clinical interaction between provider and patient in modern medical practice.

The lack of a common data registry within the DoD and VHA also has impeded responsible, data-driven decision-making on the myriad possible treatment possibilities available for pain management. This issue is particularly poignant today as integrative medicine techniques are being evaluated as possible alternatives or supplements to more standard pain-management techniques.

The Task Force agreed that the DoD and VHA require a Pain Assessment Screening Tool and Outcomes Registry (PASTOR) to collect needed clinical information from the patient about all aspects of their pain. The PASTOR system would summarize this information for clinicians, leaders and medical resource managers, providing the needed data for diagnostic and decision support. A key feature of the PASTOR system is that patients can complete the PASTOR questions online prior to their clinical appointments and in the privacy of their own home. Patients will be able to provide the needed information on their schedule, and the clinic appointment time will not be burdened with data-collection tasks. This will permit the clinician to focus on the information and the patient.

In the process of defining the requirements of the PASTOR program, the Task Force was extremely pleased to learn of the National Institutes of Health (NIH) — Patient Reported Outcomes Measurement Information System (PROMIS —http://www.nihpromis.org).  NIH has invested more than $90 million in PROMIS to develop a set of highly-researched, reliable tools that provide patient-reported health status for the psychosocial and physical functioning of the patient. While PROMIS tools are particularly suited for enhancing clinical pain medicine, they are equally appropriate for many other chronic health conditions. In fact, they were developed specifically to be appropriate for measuring symptoms and outcomes across a range of chronic conditions.

To reduce question burden for the patient, the PROMIS measures use computer-adaptive testing, with measures calibrated against the U.S. population. Therefore, responses have inherent normative meaning, because they can be directly compared to a U.S. general population sample that has been matched to the US 2000 census with respect to gender, race/ethnicity and age.

DVCIPM, in collaboration with NIH and Northwestern University’s Feinberg School of Medicine,⁵ Chicago, is actively researching and developing the PASTOR/PROMIS information system. Concurrently, the DoD is developing the information technology requirements documents with all three services to establish PASTOR/PROMIS as a key clinical information system for the near future.