Summary: Implementing Context Factors Assessment Into Clinical Settings (DI-2017C2-5778)

PCORI PROMIS Dissemination and Implementation Program
Funding period: 2018-2021
PIs: Drs. Ajay D. Wasan and Carol Greco (Pitt Department of Psychiatry)

Helping Pain Clinics Use Surveys to Understand Patient-Centered Factors that Affect Treatment

patient and doctors looking at a laptop

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward the broad use of evidence to inform healthcare decisions.

Project Description

We incorporated Healing Encounters and Attitudes Lists (HEAL) patient-reported measures into our existing Collaborative Health Outcomes Information Registry (CHOIR), an electronic platform that allows patients to complete surveys about their health. The patient surveys and associated workflows were implemented within the seven pain medicine clinics at UPMC (University of Pittsburgh Medical Center).

This project involved: 

  1. Conducting formative evaluations with staff, clinicians, and patients and programming and testing the new questions and associated reports
  2. Training clinic personnel on how to encourage patients to complete the surveys and training clinicians to use the survey results during clinical encounters to better engage patients and enhance care
  3. Conducting process evaluations and providing further training and resources as needed
  4. Conducting summative evaluations and assessing the extent to which the HEAL and CHOIR survey questions were integrated into the clinic workflows
  5. An enhancement to evaluate and continue implementation efforts during periods when clinics conducted many evaluations and treatment encounters via telemedicine due to the COVID-19 pandemic-related restrictions on in-person visits
  6. Preparation of implementation and training material costs so that other clinics and hospital systems could implement HEAL using the CHOIR patient-reported outcomes software

Implementation Strategies

  • Used a clinical decision support tool
  • Adapted HEAL based on patients’ and clinics’ preferences, as well as to work for sites’ existing resources and workflows.
  • Incorporated HEAL into CHOIR, an electronic system that allows patients to complete surveys prior to a clinic visit, and enabled generation of completed reports for patients and clinicians
  • Used data warehousing techniques
  • Used a “train-the-trainer” approach
  • Trained clinicians through in-person meetings and online videos to access, interpret, and use the HEAL reports during clinic visits
  • Trained front desk staff and medical assistants to support patients’ use of HEAL
  • Provided tools to support implementation, including clinician FAQs
  • Provided clinic-specific audit and feedback reports
  • Identified and prepared champions at sites
  • Provided educational materials to patients, including FAQ sheets
  • Provided technical assistance to sites, including ongoing consultation and practice facilitation
  • Created implementation materials

Major Achievements


During the project, 23,475 patients with chronic pain completed more than 58,000 surveys. Among patients who had clinic visits, 80% completed HEAL. Clinicians viewed 49,772 reports, or 86% of patients’ completed surveys. Before the project, clinicians viewed 76% of completed surveys.

The project team’s evaluation showed that over 27 months:

  • The total number of patients prescribed strong opioids (Schedule II) decreased from 2,313 to 1,719. This number represented a decrease from 28% to 21% among all prescriptions ordered for these patients.
  • Among patients who had clinic visits after completing HEAL, referrals for injections decreased from 39% to 27% of patients.
  • Referrals to integrative medicine increased from 0.8% to 2%. However, the total number of referrals was low compared with other types of referrals.
  • Patient-reported outcomes related to pain, function, depression, sleep, and anxiety showed greater improvement after HEAL had been added at the clinics compared to before HEAL had been included.


  • Demonstrated the feasibility of implementing HEAL in chronic pain settings
  • Created education materials and an implementation manual to facilitate use of HEAL
  • Trained 74 clinic staff members
  • Successfully implemented strategies to maximize uptake of HEAL/CHOIR during telemedicine visits as a response to the COVID-19 pandemic

Evaluation Measures

To Document Implementation

  • Number of unique patients eligible to complete HEAL
  • Number of surveys completed during the project
  • Patient survey completion rate (number of surveys completed relative to the number of appointments for which a survey was requested)
  • Number of views of clinician PDF reports of patient surveys
  • Number of clinic staff members trained

To Assess Healthcare and Health Outcomes

  • Non-opioid pain management / reduced use of strong opioids
  • Referrals to non-pharmacologic treatment approaches such as psychology, physical therapy, or occupational therapy
  • Healthcare utilization
  • PROMIS outcomes: pain intensity, pain interference, physical function, depression, anxiety

COVID-19-Related Project Activities

PCORI supplemental funding supported project activities to address needs evolving or emerging in the context of the COVID-19 public health crisis.

To reduce the risk of spreading the COVID-19 virus, many health systems shifted from in-person care to telehealth. Telehealth is a way to provide care to patients remotely using phone, video, or monitoring devices that can help manage care.

With the enhancement, the project team supported the use of HEAL in telehealth visits for patients with chronic pain. The team asked patients to fill out the survey at home instead of in the waiting room. Also, the team trained and supported clinicians on how to use the HEAL survey in telehealth visits. The team found that clinics continued to use HEAL during the pandemic. The patient survey completion rate was high (83%), and clinician views of the report were also high (96%).

More About This Implementation Project


  • University of Pittsburgh School of Medicine Chronic Pain Research Program and the Center for Innovation in Pain Care (CIPC)
  • Patient and stakeholder advisors, including an occupational therapist, physician with chronic pain expertise, patients with chronic pain, and a representative of the American Chronic Pain Association

Publicly Accessible Project Materials

The project team developed the below materials, which may be available for free or require a fee to access. Please note that the materials do not necessarily represent the views of PCORI and that PCORI cannot guarantee their accuracy or reliability. For more information about these materials, please contact the project team at

Additional Information

  • Cost of implementation table and further implementation materials will be available upon request.
  • Please complete our online survey to request additional information 


Photo credit: Close up on doctor and senior patient hands holding digital tablet with blank screen -