Determinants of ePROM Implementation and Scale-Up in Routine Care across a Universal Healthcare System: A Retrospective Population-Based Observational Study

Healthcare is slowly changing its focus from simply treating sickness to understanding the whole person. For decades, doctors have relied on their own observations and lab tests to decide how a patient is doing. But a growing number of medical experts believe that the most important data often comes directly from the people receiving care. To capture this, doctors use short, standardized questionnaires called patient-reported outcome measures. These tools ask patients to describe their own pain, mood, or quality of life in their own words, turning subjective feelings into concrete information that can guide treatment. In recent years, these paper forms have been transformed into digital versions, known as electronic patient-reported outcome measures, or ePROMs. These digital tools allow patients to fill out surveys on their phones or computers, with answers instantly appearing in a doctor's records. While this sounds efficient, putting such a system to work across an entire country is a massive logistical challenge. It requires convincing thousands of busy doctors to change their daily habits and ensuring that millions of patients can actually use the technology without getting lost or giving up.

In 2022, the public healthcare system in Catalonia, Spain, decided to tackle this challenge head-on by rolling out a system-wide program to use these digital surveys in routine care. This was not a small test in a single hospital; it was a massive effort to integrate these tools into the daily lives of nearly eight million people. Researchers later looked back at the first two years of this program to see how it actually worked. They wanted to understand what made doctors decide to use the surveys and what made patients actually complete them. By analyzing data from nearly 420,000 patients and over 11,000 healthcare workers, the team uncovered a clear picture of how a large-scale digital health system grows and where it faces friction.

The results showed that the system could indeed be implemented on a massive scale. Over the course of two years, healthcare professionals prescribed nearly 790,000 digital surveys. The usage did not happen all at once; it grew steadily, accelerating significantly after staff received training and the technology was fully woven into their existing computer systems. Once the system was running smoothly, the rate at which patients finished the surveys stabilized at a high level, with about three out of every four surveys being completed. This suggests that when digital tools are designed to fit naturally into the flow of a doctor's visit rather than being added as an extra burden, they can become a standard part of medical care.

However, the study revealed that who prescribes the survey matters far more than who the doctor is as a person. The researchers found that a doctor's job title was a much stronger predictor of how many surveys they sent out than their age, gender, or years of experience. For instance, physiotherapists, dietitians, and community wellbeing workers were far more likely to use the system than physicians or nurses, even though the latter groups were larger in number. This indicates that the specific way a professional works and the structure of their daily routine are more important than their personal demographics. The data also showed that professionals working in rural areas prescribed more surveys than those in cities, and those in areas with higher average incomes also used the system more frequently, though these differences were less dramatic than the differences based on job role.

On the patient side, the most powerful factor determining whether a survey was completed was simply how many were asked for. The more surveys a patient was given, the less likely they were to finish them all. This was a clear mathematical reality: if a patient was asked to fill out just one survey, they were very likely to do it, but as the number of requests piled up, the completion rate dropped. Interestingly, the study found that a patient's age, income, or health status had very little effect on whether they finished the surveys compared to the design of the system itself. While older patients and those with lower incomes sometimes struggled slightly more, the overall pattern suggested that the system was working fairly equitably. The researchers also looked at how patients completed the surveys, noting that most did so while sitting in the clinic, while only a small fraction used a personal patient portal to do it from home.

Ultimately, the study concluded that large-scale implementation of these digital tools is possible, but it depends heavily on how well the technology is integrated into the existing workflow. The success of the program in Catalonia was not driven by the personal characteristics of the doctors or patients, but by organizational choices and the design of the intervention itself. When the system was built to support the way healthcare professionals already worked, and when the burden on patients was managed carefully, the program succeeded. The findings suggest that for digital health tools to work everywhere, they must be designed to fit the reality of the clinic, rather than asking people to fit their lives around the technology.